Nonvariceal Gastrointestinal Bleeding Research Articles

Mo1102 Helicobacter pylori Eradication According To23s Ribosomal RNA Point Mutations

episodes were reviewed of which 63 and 75 were treated by GI and Non-GI physicians. The two groups were broadly similar in their baseline characteristics. Mean length of stay (days) was significantly shorter in the GI group: 6.6 ±5.6Vs 10.66 ±11.3 (p=0.006). Other comparators are shown in the table. Discussion: The length of stay of patients with UGIB is significantly shorter when receiving specialist care. In line with previous reports [4], we found that the incidence of UGIB was higher in males. Patients managed by GI physicians received less blood transfusion compared to the NonGI physicians. The time to endoscopy was significantly shorter when receiving specialist care. Mortality rates in both groups compared favourably to the national average.

Sa1672 Endoscopic Yield and Outcomes of Performing Urgent Versus Early Endoscopy in Acute Non-Variceal Upper Gastrointestinal Bleeding (ANVUGIB)

Sa1672 Endoscopic Yield and Outcomes of Performing Urgent Versus Early Endoscopy in Acute Non-Variceal Upper Gastrointestinal Bleeding (ANVUGIB)

Absence ofHelicobacter pyloriis not protective against peptic ulcer bleeding in elderly on offending agents: lessons from an exceptionally low prevalence population

Aim. Helicobacter pylori (H. pylori) infection is exceptionally rare in population from the north-eastern region of Peninsular Malaysia. This provides us an opportunity to contemplate the future without H. pylori in acute non-variceal upper gastrointestinal (GI) bleeding.Methods. All cases in the GI registry with GI bleeding between 2003 and 2006 were reviewed. Cases with confirmed non-variceal aetiology were analysed. Rockall score > 5 was considered high risk for bleeding and primary outcomes studied were in-hospital mortality, recurrent bleeding and need for surgery.Results. The incidence of non-variceal upper GI bleeding was 2.2/100,000 person-years. Peptic ulcer bleeding was the most common aetiology (1.8/100,000 person-years). In-hospital mortality (3.6%), recurrent bleeding (9.6%) and need for surgery (4.0%) were uncommon in this population with a largely low risk score (85.2% with score ≤5). Elderly were at greater risk for bleeding (mean 68.5 years, P = 0.01) especially in the presence of duodenal ulcers (P = 0.04) despite gastric ulcers being more common. NSAIDs, aspirin and co-morbidities were the main risk factors.Conclusions. The absence of H. pylori infection may not reduce the risk of peptic ulcer bleeding in the presence of risk factors especially offending drugs in the elderly.

Management of portal hypertensive gastropathy and other bleeding.

A major cause of cirrhosis related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Less common causes of gastrointestinal bleeding are peptic ulcers, malignancy, angiodysplasia, etc. Upper gastrointestinal bleeding has been classified according to the presence of a variceal or non-variceal bleeding. Although non-variceal gastrointestinal bleeding is not common in cirrhotic patients, gastroduodenal ulcers may develop as often as non-cirrhotic patients. Ulcers in cirrhotic patients may be more severe and less frequently associated with chronic intake of non-steroidal anti-inflammatory drugs, and may require more frequently endoscopic treatment. Portal hypertensive gastropathy (PHG) refers to changes in the mucosa of the stomach in patients with portal hypertension. Patients with portal hypertension may experience bleeding from the stomach, and pharmacologic or radiologic interventional procedure may be useful in preventing re-bleeding from PHG. Gastric antral vascular ectasia (GAVE) seems to be different disease entity from PHG, and endoscopic ablation can be the first-line treatment.

Risk factors associated with failure of endoscopic therapy for acute non-variceal upper gastrointestinal bleeding

Risk factors associated with failure of endoscopic therapy for acute non-variceal upper gastrointestinal bleeding

Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance.

Background and Aims. To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group. Methods. The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade. Results. The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke. Conclusions. The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

Endoscopic Hemostasis of Nonvariceal Gastrointestinal Bleeding

We investigated 2668 patients with non-variceal upper gastrointestinal bleeding and 660 patients with lower gastrointestinal bleeding treated between 1987 and 2011 in our hospital. Upper gastrointestinal bleeding was associated with gastric ulcer, duodenal ulcer, Mallory-Weiss syndrome, esophageal disease, and others. Endoscopic hemostasis was performed in approximately 67% of all cases with upper gastrointestinal bleeding and approximately 90% of cases with ulcer. The hemostasis success rate was over 90% for ulcer bleeding, and was also generally high for other diseases. The total number of patients with lower gastrointestinal bleeding was lower, with it being approximately 20% of those with upper gastrointestinal bleeding. Endoscopic hemostasis was performed in approximately 30% of the patients with lower gastrointestinal bleeding. The hemostasis success rate was generally high, but treatment switch to surgery or interventional radiology (IVR) was observed in some cases with colorectal diverticular bleeding.

Predicting GI Bleeding Outcomes: Inpatient vs. Outpatient

Acute nonvariceal gastrointestinal bleeding (NVGIB) during hospitalization for another condition (in-hospital bleeding; IHB) seems to result in poorer

Actualización en hemorragia gastrointestinal de origen no varicoso

This article summarizes the main studies in the field of non-variceal gastrointestinal bleeding reported in the last American Congress of Gastroenterology (Digestive Disease Week) in 2013. Some of these studies have provided new knowledge and expertise in areas of uncertainty. In this context and among other findings, it has been reported that the administration of a proton pump inhibitor (PPI) prior to endoscopy or the early performance of endoscopy–within 6 hours of admission in patients with upper gastrointestinal bleeding (UGIB) (or colonoscopy within 24 hours in patients with lower gastrointestinal bleeding)–does not improve the prognosis of the event. It has also been reported that oral administration of a PPI after endoscopic hemostasis may produce a similar outcome to that of intravenously administered PPI in patients with upper gastrointestinal bleeding (UGIB). In the field of endoscopic therapy, the use of radiofrequency ablation for antral vascular ectasia is of interest. Regarding UGIB and nonsteroidal antiinflammatory drugs (NSAIDs), new data confirm the risk of cardiovascular events by stopping treatment with acetylsalicylic acid (ASA) after an episode of UGIB, the increased risk of UGIB when associating gastrotoxic drugs, and the need to identify both the gastrointestinal and cardiovascular risks of each NSAID and coxib when prescribing these agents. Finally, there is evidence that both environmental and genetic factors are involved in individual susceptibility to gastrointestinal bleeding.

Reply

Thank you for your comments. Gastrointestinal bleeding (GIB) is not rare in patients with chronic renal failure. The common causes of GIB in these patients include gastroduodenal ulcers, erosive esophagitis/gastritis/duodenitis, and angiodysplasia (angioectasias) bleeding. In Taiwan, only one tenth of about 45,000 chronic renal failure patients underwent regular peritoneal dialysis (PD); others underwent hemodialysis (HD). Using the same database and study design (CMAJ 2011;183:E1345–E1351; Am J Med 2013;126:264.e25–32), we analyzed data from 2239 PD patients, 2328 HD patients, 2267 chronic kidney disease (CKD) patients, and 4574 controls with age and gender matching in a 1:1:1:2 ratio. Cox proportional hazard regression analysis showed that CKD (hazard ratio [HR], 3.99; 95% confidence interval [CI], 2.24–7.13) had similar risk of peptic ulcer bleeding with PD (HR, 3.71; 95% CI, 2.00–6.87). HD was most risky (HR, 11.96; 95% CI, 7.04–20.31). Regarding the issue of nonpeptic ulcer, nonvariceal bleeding, Cox regression analysis also showed that CKD (HR, 3.01; 95% CI, 1.84–6.23) had similar HR of nonpeptic ulcer, nonvariceal bleeding with PD (HR, 3.13; 95% CI, 1.87–6.41). HD also carried a greater risk (HR, 10.26; 95% CI, 6.14–17.55) than CKD and PD. In fact, HD patients are older, have worse self-care ability and performance status, and have more comorbidities than PD patients. Moreover, the use of heparin during HD seems to exaggerate bleeding risk in patients with an existing GI lesion. In facing chronic renal failure patients with risk of GIB, PD rather than HD may be a strategy to decrease GIB. Thank you for your comments. Gastrointestinal bleeding (GIB) is not rare in patients with chronic renal failure. The common causes of GIB in these patients include gastroduodenal ulcers, erosive esophagitis/gastritis/duodenitis, and angiodysplasia (angioectasias) bleeding. In Taiwan, only one tenth of about 45,000 chronic renal failure patients underwent regular peritoneal dialysis (PD); others underwent hemodialysis (HD). Using the same database and study design (CMAJ 2011;183:E1345–E1351; Am J Med 2013;126:264.e25–32), we analyzed data from 2239 PD patients, 2328 HD patients, 2267 chronic kidney disease (CKD) patients, and 4574 controls with age and gender matching in a 1:1:1:2 ratio. Cox proportional hazard regression analysis showed that CKD (hazard ratio [HR], 3.99; 95% confidence interval [CI], 2.24–7.13) had similar risk of peptic ulcer bleeding with PD (HR, 3.71; 95% CI, 2.00–6.87). HD was most risky (HR, 11.96; 95% CI, 7.04–20.31). Regarding the issue of nonpeptic ulcer, nonvariceal bleeding, Cox regression analysis also showed that CKD (HR, 3.01; 95% CI, 1.84–6.23) had similar HR of nonpeptic ulcer, nonvariceal bleeding with PD (HR, 3.13; 95% CI, 1.87–6.41). HD also carried a greater risk (HR, 10.26; 95% CI, 6.14–17.55) than CKD and PD. In fact, HD patients are older, have worse self-care ability and performance status, and have more comorbidities than PD patients. Moreover, the use of heparin during HD seems to exaggerate bleeding risk in patients with an existing GI lesion. In facing chronic renal failure patients with risk of GIB, PD rather than HD may be a strategy to decrease GIB. Causes of Gastrointestinal Hemorrhage in Patients with Chronic Renal FailureGastroenterologyVol. 145Issue 4PreviewLuo JC, Leu HB, Hou MC, et al. Nonpeptic ulcer, nonvariceal gastrointestinal bleeding in hemodialysis patients. Am J Med 2013;126:e25–32. Full-Text PDF

Causes of Gastrointestinal Hemorrhage in Patients with Chronic Renal Failure

Causes of Gastrointestinal Hemorrhage in Patients with Chronic Renal Failure

Transcatheter Intervention for Non-variceal Gastrointestinal Bleeding: What Have We Learned in 45 Years?

Despite considerable advances in diagnostic testing, medical treatment, surgical and non-surgical interventions, therapy of gastrointestinal (GI) bleeding remains a challenge for physicians. Although GI bleeding ceases spontaneously in roughly 75 % of patients, it still carries a relatively high morbidity and mortality in our aging population [1]. When faced with a bleeding patient, clinicians initially attempt to separate hemorrhage arising in the upper gastrointestinal (UGI) tract from that originating in the lower gastrointestinal (LGI) tract, delineated by the ligament of Treitz, due to the considerable differences in diagnosis, treatment and prognosis associated with each region. Regardless of location, endovascular interventions remain important for the diagnosis and treatment of GI bleeding, likely only increasing in application and efficacy in the coming decades. Before 1968, endovascular physicians had little to offer the acutely bleeding patient. The first major therapeutic intervention for GI bleeding was catheter directed intraarterial vasopressin infusion [2]. A somewhat cumbersome procedure that has largely been abandoned in contemporary practice, vasoconstrictor infusion offered a minimally invasive therapy that could be employed in stable and unstable patients alike, for variceal and non-variceal hemorrhage [3]. In the 1970s, arterial embolization initially appeared promising, although its widespread adoption was thwarted by unacceptably high complication rates, primarily colonic ischemia [4]. When technological advances in imaging, embolic agents, and catheters caught up with physician ingenuity in the late 1990s and early 2000s, a paradigm switch occurred with arterial embolization assuming primacy for catheter-based therapy of UGI and LGI bleeding. In the past several years, numerous studies, predominantly retrospective series, have reported the safety and efficacy of arterial embolization for UGI and LGI bleeding [5–7]. Although published algorithms for the management of GI bleeding exist, the application of mesenteric angiography with transcatheter arterial embolization in the therapy of GI hemorrhage remains controversial. The study by Yap et al. [8] in this issue describes a single-center experience with transcatheter arterial embolization for non-variceal GI bleeding over a period of 8 years. The authors demonstrate a high technical success rate in keeping with other reported series and national guidelines. Of note, the data are reported without strict separation of UGI from LGI bleeding, which dilutes their conclusions. Despite this limitation, the authors provide a detailed look at patients requiring transcatheter arterial embolization, and identify important risk factors for rebleeding, notably underlying peptic ulcer disease and coagulopathy. Their experience highlights an important concept in the endovascular treatment for GI bleeding; embolization in the UGI tract can either be ‘‘targeted’’ at visualized arterial abnormalities, or ‘‘empiric’’, where the suspected culprit arterial branch is occluded despite no demonstrated angiographic abnormality. In the LGI tract, where the collateral arterial supply is tenuous, targeted embolization is recommended such as in the accompanying article, D. S. BouHaidar (&) Department of Internal Medicine, Interventional Endoscopy, Virginia Commonwealth University Health Center, Box 980341, Richmond, VA 23298-0341, USA e-mail: dsbouhaidar@vcu.edu

Mallory–Weiss Syndrome: Where to Look, How to Detect

Mallory–Weiss syndrome is a common cause of upper nonvariceal gastrointestinal bleeding. Although considered minor, it can occasionally cause severe bleeding and have fatal outcome in high-risk patients. Careful inspection is needed to assess the depth of the tear and the presence of major stigmata of hemorrhage. Endoscopic therapy is rarely required. Mechanical hemostasis by means of clip application or band ligation is considered the option of choice in these patients. This article is part of an expert video encyclopedia.

Su1913 Prognostic Factors for in-Hospital Mortality in Patients With Non-Variceal Upper Gastrointestinal Tract Bleeding

Su1913 Prognostic Factors for in-Hospital Mortality in Patients With Non-Variceal Upper Gastrointestinal Tract Bleeding

Sa1607 Localization of Angioectasias in the Small Bowel Using Capsule Endoscopy

Predicting Acute Non-Variceal Upper Gastrointestinal Bleeding Which System Triages Best? Jack Kian Ch’NG, Yirong Sim*, Weng Hoong Chan, Yaw Chong Goh, Hock Soo Ong, Wai Keong Wong General Surgery, Singapore General Hospital, Singapore, Singapore Background: Acute non-variceal upper gastrointestinal bleeding (UGIB) remains a significant health problem and constitutes a significant proportion of emergency surgical admissions. The frequency and severity of this problem and its associated costs impose a significant burden on health care resources. Therefore, a triage system that can differentiate high and low risk patients for UGIB at initial presentation before offering emergency endoscopy is vital in guiding in hospital treatment. Several scoring systems have been devised to predict the severity of UGIB and the need for intervention, but have not been validated in our local (Singapore) setting. A highly predictive model for significant UGIB will guide the allocation of an appropriate level of care at admission, including emergent endoscopy. Aim: To validate and compare the Rockall and Blatchford score in predicting outcome after acute non-variceal upper gastrointestinal bleeding and the need for intervention. Methods: This is a single centre retrospective study conducted in Singapore General Hospital. All patients diagnosed with UGIB between January to December 2010 were included into the study. Data collected include demographics, mode of presentation, comorbidities, initial haemodynamic status, and initial haemoglobin level and blood biochemistry before transfusion. The 3 outcomes of interest were intervention (blood transfusion, endoscopy or surgery), re-bleeding and mortality. External validation of Clinical Rockall, Complete Rockall and Blatchford scoring schemes were evaluated by assessing discrimination and calibration. Area under the receiver operating characteristics curve (AUROC) was used as a measure of discrimination; calibration was evaluated using chi-squared Statistical software, SPSS version 17.0 was used for all analysis. Results: In the year 2010, 348 patients presented to our institute with UGIB and were analysed. There were almost twice as many males (65.2%) than females (34.8%) patients who presented with UGIB, with a mean age of 65 years. The most common mode of presentation is malaena (66.4%). Re-bleeding and mortality rate were 30.7% and 4.0% respectively. Clinical Rockall score, complete Rockall score and Blatchford score were significant associated with rebleed, mortality and intervention (p 0.05). Comparing AUROCs, the Blatchford scoring system was superior in identifying UGIB patients who require intervention, and are at risk of rebleeding. When a cut-off score value of 2 was used, the sensitivity and specificity of the Blatchford scoring system were determined to be 100% and 18.9% respectively. Conclusion: In our local population, the Blatchford score is superior in predicting low-risk patients who do not require urgent therapeutic endoscopy and who may be suitable for outpatient management.

Sa1606 Predicting Acute Non-Variceal Upper Gastrointestinal Bleeding - Which System Triages Best?

Sa1606 Predicting Acute Non-Variceal Upper Gastrointestinal Bleeding - Which System Triages Best?

Rescue endoscopic bleeding control for nonvariceal upper gastrointestinal hemorrhage using clipping and detachable snaring

Nonvariceal upper gastrointestinal (UGI) bleeding recurs after appropriate endoscopic therapy in 10 % - 15 % of cases. The mortality rate can be as high as 25 % when bleeding recurs, but there is no consensus about the best modality for endoscopic re-treatment. The aim of this study was to evaluate clipping and detachable snaring (CDS) for rescue endoscopic control of nonvariceal UGI hemorrhage. We report a case series of seven patients from a Korean tertiary center who underwent endoscopic hemostasis using the combined method of detachable snares with hemoclips. The success rate of endoscopic hemostasis with CDS was 86 %: six of the seven patients who had experienced primary endoscopic treatment failure or recurrent bleeding after endoscopic hemostasis were treated successfully. In conclusion, rescue endoscopic bleeding control by means of CDS is an option for controlling nonvariceal UGI bleeding when no other method of endoscopic treatment for recurrent bleeding and primary hemostatic failure is possible.

Acute nonvariceal upper gastrointestinal bleeding—experience of a tertiary care center in southern India

Over the last few decades, epidemiologic studies from the West have shown changing trends in etiology and clinical outcomes in patients with nonvariceal upper gastrointestinal bleed (NVUGIB). There are limited data from India on the current status of NVUGIB. The aim of this study therefore was to assess the etiological profile and outcomes of patients with NVUGIB at our center. We prospectively studied all patients (≥15 years) who presented with NVUGIB over a period of 1 year. The clinical and laboratory data, details of endoscopy, and course in hospital were systematically recorded. Outcome measures assessed were rebleeding rate, surgery, and mortality. Two hundred and fourteen patients (age, ≥15 years) presented to us with NVUGIB during the study period. The mean age was 49.9 ± 16.8 years and 73.8 % were males. Peptic ulcer was the commonest cause (32.2 %) of NVUGIB. About one third of patients required endoscopic therapy. Rebleeding occurred in 8.9 % patients, surgery was required in 3.7 %, and mortality rate was 5.1 %. Rebleeding and mortality were significantly higher among inpatients developing acute NVUGIB compared to those presenting directly to the emergency room. Peptic ulcer was the most common cause of NVUGIB. Outcomes (rebleed, surgery, and mortality) at our center appear similar to those currently being reported from the West.

Letter: is blood transfusion really a risk factor for rebleeding in nonvariceal gastrointestinal bleeding?

Letter: is blood transfusion really a risk factor for rebleeding in nonvariceal gastrointestinal bleeding?

Letter: is blood transfusion really a risk factor for rebleeding in nonvariceal gastrointestinal bleeding? Authors’ reply

We thank Dr Lin for his comments1 and the opportunity to emphasise important aspects of our recently published analysis.2, 3 In fact, we indeed performed thorough multivariable risk adjustment for all of factors listed by Dr Lin. We adjusted for blood on rectal examination or in the nasogastric tube aspirate, ASA score, co-morbidities, haemodynamic instability, initial haemoglobin, use of fresh frozen plasma, red blood cell transfusion, presence of high risk endoscopic stigmata, performance of endoscopic therapy and proton pump inhibitor use. We included all parameters found in the Blatchford scale except for urea,4 as the data used in this analysis were also used to validate a modified Blatchford scale that excludes urea.5 Our results, and those of a large UK audit,6 suggest that transfusion practice, and more specifically blood administration in the first 24 h, may independently predict poorer outcomes. This observation was recently validated in a large randomized trial of patients with upper gastrointestinal bleeding, and more specifically amongst class A and B cirrhotic patients.7 Unfortunately, issues of generalisability in the aforementioned trial prevent definitive conclusions about the impact of transfusion policy on the outcomes of patients with nonvariceal bleeding; importantly, additional information will soon be available from a cluster randomized trial in the United Kingdom.8 In the interim, based on all currently available evidence, clinicians should continue to follow consensus recommendations for patients with nonvariceal bleeding. We would also like to correct Dr Lin regarding his comments about current recommendations. The 2010 International Consensus Group in fact suggested a restrictive transfusion practice, with blood transfusions administered to patients with a haemoglobin level of 7 g/dL or less, pending further data.8 Furthermore, threshold haemoglobin levels of 6–10 g/dL may warrant transfusion in patients with underlying cardiac disease.9 The authors’ declarations of personal and financial interests are unchanged from those in the original article.2