Nonvariceal Upper Gastrointestinal Research Articles

Racial Differences in Non-variceal Upper Gastrointestinal (GI) Bleeding: A Nationwide Study.

Background and aims Knowledge about the impact of race on non-variceal upper GI bleeding (NVUGIB) is limited. This study explored the racial differences in the etiology and outcome of NVUGIB. Methods We conducted a study from 2009 to 2014 using the Nationwide Inpatient Sample (NIS) database. NIS is the largest publicly available all-payer inpatient database in the USA with more than seven million hospital stays each year. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for NVUGIB, esophagogastroduodenoscopy (EGD) and demographics were obtained. The outcomes of interest were in-hospital mortality, hospital length of stay (HLOS), total hospital charges, admission to the intensive care unit (ICU), and patient disposition. Analysis was conducted using Chi-square tests and Tukey multiple comparisons between groups. Results Among 1,082,516 patients with NVUGIB, African American and Native Americans had the highest proportions of hemorrhagic gastritis/duodenitis (8.2% and 4.2%, respectively) and Mallory-Weiss bleeding (10.4% and 5.4%, respectively; p<0.01). African Americans were less likely to get an EGD done within 24 hours of admission compared to Whites and Latinxs (45.9% vs 50.1% and 50.4%, respectively; p<0.001). In-hospital mortality was similar among African Americans, Latinxs, and Whites (5.8% vs 5.6% vs 5.9%, respectively; p=0.175). Asian/Pacific Islanders and African Americans were more likely to be admitted to the ICU (9.6% and 9.0%, respectively; p<0.001). Moreover, African Americans had a longer HLOS compared to Latinxs and Whites (7.5 vs 6.5 and 6.4 days, respectively; p<0.001). Conversely, Asian/Pacific Islanders and Latinx incurred the highest hospital total charges compared to African Americans and Whites ($81,821 and $69,267 vs $61,484 and $53,767, respectively; p<0.001). Conclusion African Americans are less likely to receive EGD within 24 hours of admission and are more likely to be admitted to the ICU with prolonged hospital lengths of stay. Latinxs are more likely to be uninsured and incur the highest hospital costs.

Hemospray Versus Conventional Therapy for Non-variceal Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Hemospray (TC-325; Cook Medical, Winston-Salem, NC) has been used effectively in hemostasis in non-variceal upper gastrointestinal (GI) bleeding. Current guidelines suggest using Hemospray as a temporizing measure or adjunct technique. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of Hemospray as a modality for primary hemostasis. We searched MEDLINE, CENTRAL, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) databases from inception to August 1, 2022. Three independent reviewers performed a comprehensive review of all original articles describing the application of Hemospray as the primary method of hemostasis in non-variceal upper GI bleeding patients. Three reviewers independently reviewed and abstracted data and assessed study quality using the Cochrane risk of bias tool. Primary outcomes were (1) primary hemostasis rate, (2)rebleeding rate until hospital discharge or death, (3)need for surgery, and (4) overall mortality rate. Of the 211 studies identified, 146 underwent title and abstract review, and four were included in the systematic review. Pooled results from 303 patients showed that compared to standard of care, Hemospray has significantly higher odds of primary hemostasis (OR: 3.48, 95% CI: 1.09-11.18, p = 0.04). There was no statistically significant difference in terms of rebleeding rates (OR: 0.79, 95% CI: 0.24-2.55, p = 0.69), need for surgery (OR: 1.62, 95% CI: 0.35-7.41, p = 0.54), or overall mortality (OR: 1.08, 95% CI: 0.56-2.08, p = 0.83). This systematic review and meta-analysis provethat Hemospray is a better modality of primary hemostasis in non-variceal upper GI bleeding when used as a primary method. At the same time, there is no significant difference in complications, including rebleeding, need for surgical intervention, and all-cause mortality.

Age, blood tests and comorbidities and AIMS65 risk scores outperform Glasgow-Blatchford and pre-endoscopic Rockall score in patients with upper gastrointestinal bleeding.

Upper gastrointestinal (GI) bleeding is a life-threatening condition with high mortality rates. To compare the performance of pre-endoscopic risk scores in predicting the following primary outcomes: In-hospital mortality, intervention (endoscopic or surgical) and length of admission (≥ 7 d). We performed a retrospective analysis of 363 patients presenting with upper GI bleeding from December 2020 to January 2021. We calculated and compared the area under the receiver operating characteristics curves (AUROCs) of Glasgow-Blatchford score (GBS), pre-endoscopic Rockall score (PERS), albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 (AIMS65) and age, blood tests and comorbidities (ABC), including their optimal cut-off in variceal and non-variceal upper GI bleeding cohorts. We subsequently analyzed through a logistic binary regression model, if addition of lactate increased the score performance. All scores had discriminative ability in predicting in-hospital mortality irrespective of study group. AIMS65 score had the best performance in the variceal bleeding group (AUROC = 0.772; P < 0.001), and ABC score (AUROC = 0.775; P < 0.001) in the non-variceal bleeding group. However, ABC score, at a cut-off value of 5.5, was the best predictor (AUROC = 0.770, P = 0.001) of in-hospital mortality in both populations. PERS score was a good predictor for endoscopic treatment (AUC = 0.604; P = 0.046) in the variceal population, while GBS score, (AUROC = 0.722; P = 0.024), outperformed the other scores in predicting surgical intervention. Addition of lactate to AIMS65 score, increases by 5-fold the probability of in-hospital mortality (P < 0.05) and by 12-fold if added to GBS score (P < 0.003). No score proved to be a good predictor for length of admission. ABC score is the most accurate in predicting in-hospital mortality in both mixed and non-variceal bleeding population. PERS and GBS should be used to determine need for endoscopic and surgical intervention, respectively. Lactate can be used as an additional tool to risk scores for predicting in-hospital mortality.

Mutliple Myeloma Increases the Mortality Rate in Patients Admitted for Upper GI Bleed: An Analysis of National Inpatient Database

Introduction Multiple myeloma is a malignant disease of terminally differentiated B cells presenting with bone lesions, renal abnormalities, electrolyte changes and infections. It can occasionally leave the bone medullary space and involve other systems like respiratory and gastrointestinal (GI) tract to form plasmacytomas. The extramedullary spread into the GI tract results in typical presentation of hematemesis and melena. There have been a few cases that have reported the same, but the true prevalence and mortality of these patients is not well known. The aim of the study was to evaluate role of multiple myeloma on the in-hospital outcomes in patients admitted for Upper GI bleed in the United States. Methodology We conducted retrospective analysis utilizing Nationwide Inpatient Database (NIS) from year 2016-2019. Patients with age 18 years or more admitted to the hospital due to non-variceal Upper GI bleed were included in our study and it was further divided based on presence (study group) or absence (control group) of underlying Multiple Myeloma. ICD-10 CM codes were used to identify patient population. Chi-square test was used to compare categorical variables and Wilcoxon rank sum test for continuous variables. Impact of multiple myeloma on the in-hospital outcomes and healthcare utilization was evaluated using multivariate logistic regression analysis. Results The sample size included 1,007,765 patients admitted for upper GI bleed, of which 0.31% had underlying multiple myeloma. Patients with underlying multiple myeloma were relatively older with mean age of 72 years compared to 65 years in group with no multiple myeloma (p<0.001). Females constituted 40.36% of the multiple myeloma group compared to 44.63% of patients without it. There was a higher mortality rate (5.03%) in those with multiple myeloma compared to those without it (1.9%) (adjusted OR=2.53, p<0.001). They also had a higher rate of blood transfusion (45.22% vs 33.91%) compared to those with no underlying multiple myeloma (adjusted OR=1.42, p<0.001). The adjusted mean total hospitalization charge was $14,531 higher and adjusted mean length of stay was 1.1 day more in those with underlying multiple myeloma compared to those without it, with p<0.001. Conclusion Our study showed that Multiple Myeloma increases the mortality rate by more than two and half fold in patients presenting with upper GI bleed. It also poses a significant burden on the healthcare and therefore, physicians should be more vigilant when encountered with such challenges. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Octreotide Efficacy and Safety in Pediatric Non-variceal Upper Gastrointestinal Bleeding: A Randomized Placebo-Controlled Clinical Trial

Background: Octreotide has been used to control bleeding episodes with variceal origin in the pediatric population. To date, there is no clear evidence of octreotide use for non-variceal bleeding in clinical trials. Objectives: We aimed to assess the octreotide efficacy as an add-on therapy to the conventional regimen of proton pump inhibitors for controlling upper non-variceal gastrointestinal (GI) bleeding in the pediatric population. Methods: This prospective randomized controlled clinical trial was performed on pediatric patients aged 1 - 15 years and diagnosed with acute non-variceal upper GI bleeding. The participants were allocated to receive octreotide or placebo and pantoprazole concomitantly. The study was conducted in Mofid Children’s Hospital, Tehran, Iran, during February 2019 - December 2019. Patients with hepatic failure, liver stigma, and coagulopathy due to thrombocytopenia were excluded. Demographic, clinical, and preclinical data were recorded in prepared sheets. All the patients were followed until therapy discontinuation. P-value &lt; 0.05 was considered significant. Results: Forty-three patients with a mean age of 4.98 ± 3.79 years and confirmed non-variceal upper GI bleeding were included in the present study. Most patients had no specific etiology for their bleeding episodes. Patients in the intervention and control groups received pantoprazole in comparable doses. No differences were observed between the two groups in terms of baseline hemoglobin values (P = 0.08), while final hemoglobin values were significantly higher in the intervention group (P = 0.014). The bleeding duration was not significantly different between the two groups (P = 0.99). Moreover, none of the cases showed adverse drug reactions due to octreotide infusion. Conclusions: Our study demonstrated that octreotide did not alter bleeding duration or need for blood transfusion. However, positive results were observed for hemoglobin, affecting blood loss volume.

Effective hemostasis by use of hemospray in a case of severe bleeding in the jejunum

Gastrointestinal (GI) bleeding remains one the most common life-threatening emergencies associated with high morbidity and mortality and requires rapid and effective endoscopic hemostasis. Despite several available endoscopic hemostatic methods (injection therapy, mechanical and thermal therapy), the treatment of small bowel bleeding is still challenging, and successful hemostasis can be difficult to achieve. One of the novel topical hemostatic agents (Hemospray; Cook Medical, Winston-Salem, NC) was approved for the management of non-variceal upper GI bleeding, and clinical efficacy was shown for GI bleeding due to peptic ulcer, malignancy, gastric variceal hemorrhage, antithrombotic therapy, and lower GI bleeding [1- 5].

Short-term, medium-term, and long-term risks of nonvariceal upper gastrointestinal bleeding after dengue virus infection.

Dengue patients have an increased risk of acute gastrointestinal (GI) bleeding. However, whether dengue virus (DENV) infection can cause an increased long-term risk of GI bleeding remains unknown, especially among elderly individuals who commonly take antithrombotic drugs. A retrospective population-based cohort study was conducted by analyzing the National Health Insurance Research Databases. Laboratory-confirmed dengue patients from 2002 to 2012 and four matched nondengue controls were identified. Multivariate Cox proportional hazard regression was used to evaluate the acute (<30 days), medium-term (31–365 days), and long-term (>365 days) risks of nonvariceal upper GI bleeding after DENV infection. Stratified analyses by age group (≤50, 51–64, ≥65 years old) were also performed. In total, 13267 confirmed dengue patients and 53068 nondengue matched controls were included. After adjusting for sex, age, area of residence, comorbidities, and medications, dengue patients had a significantly increased risk of nonvariceal upper GI bleeding within 30 days of disease onset (adjusted HR 55.40; 95% CI: 32.17–95.42). However, DENV infection was not associated with increased medium-term and long-term risks of upper GI bleeding overall or in each age group. Even dengue patients who developed acute GI bleeding did not have increased medium-term (adjusted HR; 0.55, 95% CI 0.05–6.18) and long-term risks of upper GI bleeding (adjusted HR; 1.78, 95% CI 0.89–3.55). DENV infection was associated with a significantly increased risk of nonvariceal upper GI bleeding within 30 days but not thereafter. Recovered dengue patients with acute GI bleeding can resume antithrombotic treatments to minimize the risk of thrombosis.

Management of Non-Variceal Upper GI Bleeding in the Geriatric Population: An Update

Upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality in the geriatric (age > 65years) population and presents a unique management challenge in the context of multiple medical comorbidities, polypharmacy, and increased risk of adverse outcomes and is confounded by an increased prevalence of obscure GI bleeds. A review of relevant guidelines, literature, and personal observations will enhance management strategies in the elderly. Non-variceal bleeding represents a significant proportion of upper GI bleeding (UGIB) in geriatric patients. Peptic ulcer disease (PUD) remains the most common cause in geriatric patients hospitalized for UGIB, but its incidence is decreasing. Esophagogastroduodenoscopy (EGD) is the gold standard for treating UGIB in geriatrics with a therapeutic yield of approximately 75%. Scoring systems such as Glasgow-Blatchford (GBS) and AIMS-65 may be useful for risk stratification but are not validated in trials. Obscure bleeds account for up to 30% of hospitalizations and must be considered during triage and management. Video capsule endoscopy (VCE) technology is efficacious for detecting obscure jejunal bleeding after failed EGD and may enhance the yield of balloon-assisted enteroscopy (BAE). The most significant factor for the increased morbidity and mortality in the geriatric population is the presence of multiple medical comorbidities and polypharmacy. An EGD should be done within 24h of hospital presentation. If non-diagnostic, VCE may be a viable option for diagnosing an obscure small-bowel bleed, representing up to 30% of GI bleeds in this population.

Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis

BackgroundConventional endoscopic treatments can’t control bleeding in as many as 20% of patients with non-variceal gastrointestinal (GI) bleeding. Recent studies have shown that over-the-scope-clip (OTSC) system allowed for effective hemostasis for refractory GI bleeding lesions. So we aimed to conduct a systematic review to evaluate the effectiveness and safety of the OTSC system for management of acute non-variceal upper GI bleeding.MethodA comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2007 to May 2019. The literature was selected independently by two reviewers according to the inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0.ResultsA total of 16 studies including 769 patients with 778 GI bleeding lesions were identified. Pooled technical success was achieved in 761 lesions [95.7%; 95% confidence interval (CI), 93.5–97.2%], and the pooled clinical success was achieved in 666 lesions (84.2, 95% CI, 77.4–89.2%). The incidence of re-bleeding was reported in 81 patients and the post-procedure mortality was 10.9% (n = 84). Only 2 (0.3%) patients occurred complications after OTSC system procedure.ConclusionsOur study demonstrated that the OTSC system was a technically feasible modality and highly efficacious in achieving hemostasis in acute non-variceal upper gastrointestinal bleeding.

AIMS65 scoring system is comparable to Glasgow-Blatchford score or Rockall score for prediction of clinical outcomes for non-variceal upper gastrointestinal bleeding

BackgroundRisk stratification for patients with nonvariceal upper gastrointestinal (NVUGI) bleeding is crucial for successful prognosis and treatment. Recently, the AIMS65 score has been used to predict mortality risk and rebleeding. The purpose of this study was to compare the performance of the AIMS65 score with the Glasgow-Blatchford score (GBS), Rockall score, and pre-endoscopic Rockall score in Korea.MethodsWe retrospectively studied 512 patients with NVUGI bleeding who were treated at a university hospital between 2013 and 2016. The AIMS65, GBS, Rockall score, and pre-endoscopic Rockall score were used to stratify patients based on their bleeding risk. The primary outcome was in-hospital mortality. The secondary outcomes were composite clinical outcomes of mortality, rebleeding, and intensive care unit (ICU) admission. Each scoring system was compared using the receiver-operating curve (ROC).ResultsA total of 17 patients (3.3%) died and rebleeding developed in 65 patients (12.7%). Eighty-six patients (16.8%) required ICU admission. The AIMS65 (area under the curve (AUC) 0.84, 95% confidence interval, 0.81–0.88)) seemed to be superior to the GBS (AUC 0.72, 0.68–0.76), the Rockall score (AUC 0.75, 0.71–0.79), or the pre-endoscopic Rockall score (AUC 0.74, 0.70–0.78) in predicting in-hospital mortality, but there was not a statistically significant difference between the groups (P = 0.07). The AUC value of the AIMS65 was not significantly different from the other scoring systems in prediction of rebleeding, endoscopic intervention, or ICU admission.ConclusionsThe AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting the mortality, rebleeding, or ICU admission. Because AIMS65 is a much easier, readily calculated scoring system compared to the others, we would recommend using the AIMS65 in daily practice.

Rising Events and Improved Outcomes of Gastrointestinal Bleed With Shock in USA: A 12-year National Analysis.

Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock. We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products. GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%). GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.

Gastric antral vascular ectasia should not be overlooked in erythropoietin resistance: a series of case reports

Gastric antral vascular ectasia (GAVE) is currently recognized as an important cause of upper gastrointestinal (GI) haemorrhage, being responsible for about 4% of non-variceal upper GI haemorrhages and typically presents in middle-aged females. GAVE, also called "watermelon stomach", is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum. The pathogenesis is still obscure and many hypotheses have been proposed such as mechanical stress, humoral and autoimmune factors. In the last two decades, numerous therapeutic strategies have been proposed, including surgical, endoscopic, and medical choices, yet successful treatment of GAVE continues to be a challenge. Currently, given the rapid response, safety, and efficacy, endoscopic ablative modalities have largely usurped medical treatments as first-line therapy, particularly using argon plasma coagulation. The actual GAVE prevalence in patients with end-stage renal disease (ESRD) is not clear, yet in difficult cases it should be considered as a cause of erythropoietin resistance. We report four clinical cases of GAVE syndrome patients diagnosed with stage 4 to 5 chronic kidney disease. All patients presented with anaemia and GI haemorrhage, the origin of which turned out to be GAVE syndrome. GAVE syndrome is a serious condition in ESRD patients, especially in those presenting with treatment-refractory anaemia. Realization of its aetiology and characteristics is essential to suspect, diagnose, and treat gastric ectasia. Only proper diagnosis and well-timed disease treatment can significantly improve a patient's medical condition and future prognosis.

Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline.

In order to address the status of gastrointestinal (GI) endoscopy in Africa, a European Society of Gastrointestinal Endoscopy (ESGE) International Affairs Working Group (IAWG) was established with participation from the World Endoscopy Organization (WEO) 1 . A previous survey conducted by the IAWG on the main indications of GI endoscopy in African countries showed nonvariceal upper GI hemorrhage (NVUGIH) to be among the top three indications 1 . This indication may reflect the very high prevalence of Helicobacter pylori infection, which is well known to be associated with gastroduodenal peptic ulcers and their complications, such as bleeding. In addition, the increased use of aspirin as prevention and treatment of cardiovascular disease, and the increase in life expectancy, may also, at least in part, account for the NVUGIH indication 2 3 4 . The management of NVUGIH requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, and drugs. Such an approach is clearly sensitive to organizational, medical, pharmaceutical, and technological resources. However, the lack of structural endoscopic and clinical health resources in some underserved African areas is likely to affect the clinical outcome of patients with NVUGIH. In this regard, the previous IAWG survey revealed several critical needs in training, education, and technology that may represent a barrier to adequate NVUGIH management 1 . Most of the respondents from the African countries participating in the IAWG survey reported a lack of national guidelines for GI endoscopy; however, there was interest in the international guidelines, pending adaptation to reflect the endoscopic resources available in their regions. For this reason, the IAWG decided to apply the cascade methodology to adapt ESGE guidelines to resource-sensitive settings in partnership with African experts 1 . Cascade guidelines are resource oriented and provide hierarchical recommendations based on the resources available to the medical care provider 5 6 . In detail, four levels of resource availability – basic, limited, enhanced, and maximal levels – are identified, with most of the interest being in the basic and limited levels. We aimed to standardize the management of NVUGIH in low-resources setting. Here, we report the cascade adaptation of the ESGE guideline on the diagnosis and management of NVUGIH 7 .

What Does Lesion Blood Flow Tell Us About Risk Stratification and Successful Management of Non-variceal UGI Bleeding?

There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).

Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series.

Gastrointestinal bleeding is one of the most common indications for urgent endoscopy in the pediatric setting. The majority of these procedures are performed for control of variceal bleeding, with few performed for nonvariceal upper gastrointestinal (NVUGI) bleeding. The data on therapeutic endoscopy for NVUGI are sparse. The aims of our study were to review our experience with NVUGI bleeding, describe technical aspects and outcomes of therapeutic endoscopy, and determine gastroenterology fellows' training opportunities according to the national training guidelines. We performed a retrospective review of endoscopy database (Endoworks, Olympus Inc, Center Valley, PA) from January 2009 to December 2014. The search used the following keywords: bleeding, hematemesis, melena, injection, epinephrine, cautery, clip, and argon plasma coagulation. The collected data included demographics, description of bleeding lesion and medical/endoscopic therapy, rate of rebleeding, relevant laboratories, physical examination, and need for transfusion and surgery. The study was approved by the institutional review board. During the study period 12,737 upper endoscopies (esophagogastroduodenoscopies) were performed. A total of 15 patients underwent 17 esophagogastroduodenoscopies that required therapeutic intervention to control bleeding (1:750 procedures). The mean ± standard deviation (median) age of patients who required endoscopic intervention was 11.6 ± 6.0 years (14.0 years). Seven out of 17 patients received dual therapy to control the bleeding lesions. All but 3 patients received medical therapy with intravenous proton pump inhibitor, and 3 received octreotide infusions. Six of the patients experienced rebleeding (40%), with 4 out of 6 initially only receiving single modality therapy. Two of these patients eventually required surgical intervention to control bleeding and both patients presented with bleeding duodenal ulcers. There were no cases of aspiration, perforation, or deaths. There were a total of 24 fellows trained in our program during the study period. Less than 1 therapeutic endoscopy per fellow for NVUGI bleeding was performed. NVUGI bleeding requiring therapeutic endoscopic intervention is rare in pediatrics. A high rate (40%) of rebleeding was noted with a large proportion (66%) of patients receiving single modality therapy. Two patients required surgical intervention to control bleeding and both presented with bleeding duodenal ulcers. An insufficient number of therapeutic procedures is available for adequate fellow training requiring supplemental simulator and hands-on animal model, or adult endoscopy unit training.

Early versus late bedside endoscopy for gastrointestinal bleeding in critically ill patients

Background/AimsGastrointestinal (GI) bleeding is a life-threatening complication in critically ill patients. The aim of this study was to determine the efficacy of bedside endoscopy in an intensive care unit (ICU) setting, and to compare the outcomes of early endoscopy (within 24 hours of detecting GI bleeding) with late endoscopy (after 24 hours).MethodsWe retrospectively reviewed the medical records of patients who underwent bedside endoscopy for nonvariceal upper GI bleeding and lower GI bleeding that occurred after ICU admission at Seoul National University Hospital from January 2010 to May 2015.ResultsTwo hundred and fifty-three patients underwent bedside esophagogastroduodenoscopy (EGD) for upper GI bleeding (early, 187; late, 66) and 69 underwent bedside colonoscopy (CS) for lower GI bleeding (early, 36; late, 33). Common endoscopic findings were peptic ulcer, and acute gastric mucosal lesion in the EGD group, as well as ischemic colitis and acute hemorrhagic rectal ulcers in the CS group. Early EGD significantly increased the rate of finding the bleeding focus (82% vs. 73%, p = 0.003) and endoscopic hemostasis (32% vs. 12%, p = 0.002) compared with late EGD. However, early CS significantly decreased the rate of identifying the bleeding focus (58% vs. 82%, p = 0.008) and hemostasis (19% vs. 49%, p = 0.011) compared with late CS due to its higher rate of poor bowel preparation and blood interference (38.9% vs. 6.1%, p = 0.035).ConclusionsEarly EGD may be effective for diagnosis and hemostatic treatment in ICU patients with GI bleeding. However, early CS should be carefully performed after adequate bowel preparation.

Endoscopic Management of Gastrointestinal Leaks and Bleeding with the Over-the-Scope Clip: A Prospective Study.

Background/AimsThe over-the-scope clip (OTSC) is a device used for endoscopic closure of perforations, leaks and fistulas, and for endoscopic hemostasis. To evaluate the clinical effectiveness and safety of OTSC.MethodsBetween October 2013 and November 2015, 12 patients underwent OTSC placement by an experienced endoscopist. OTSC was used for the closure of gastrointestinal (GI) leaks and fistula in six patients, three of which were iatrogenic (esophageal, gastric, and duodenal) and three of which were inflammatory. In six patients, OTSC was used for hemostasis of non-variceal upper GI bleeding. Endoscopic tattooing using India ink was used to assist the accurate placement of the clip.ResultsAll subjects except one with a colonic defect experienced immediate technical success as well as long-term clinical success, during a mean follow-up of 6 weeks. Only one clip was required to close each of the GI defects and to achieve hemostasis in all patients. There were no misfirings or complications of clips. The procedure was well tolerated, and patients were hospitalized for an average of 8 days (range, 3 to 10). Antiplatelet therapy was continued in patients with GI bleeding.ConclusionsIn our experience, OTSC was safe and effective for the closure of GI defect and to achieve hemostasis of non-variceal GI bleeding.

Gastric Antral Vascular Ectasia and Underlying Microvascular or Vascular Disease: Is There an Association?

Introduction: Gastric antral vascular ectasia (GAVE) is an important cause of chronic gastrointestinal (GI) bleeding accounting for 4% of non-variceal upper GI bleeding. It has been classically associated with cirrhosis, chronic kidney disease (CKD), hypothyroidism and autoimmune (AI) disorders. We aim to describe the clinical profile of patients with GAVE without known cirrhosis and to elucidate any associations with concomitant vascular or microvascular disorders. Methods: A retrospective study was conducted that included all patients diagnosed with GAVE without underlying cirrhosis (group 1). GAVE was diagnosed based on endoscopic appearance. An age and sex matched group of patients with cirrhosis and GAVE (group 2) was also included to serve as the control group. Information on demographics and co-morbid conditions like hypertension (HTN), diabetes mellitus I/II (DM), CKD, AI diseases, peripheral arterial disease requiring intervention (PAD), coronary artery disease (CAD), cerebrovascular disease (CVD) and smoking history was collected. Unpaired t-test was used to determine significance. Results: Seventeen patients were included in group 1 (mean age 65.3+15.1 years, women 70.6%) and group 2 (mean age 65.1+6.5 years, women 70.6%) each. Mean BMI was 29.8+6.5 (group 1) and 31.9+5.1 (group 2) respectively (p=0.300). Comparing group 1 vs. group 2, only CAD with a prevalence of 58.8% and 17.6%, respectively [p-value=0.0042] was statistically significant. PAD with a prevalence of was 17.6% (group 1) and 0% (group 2) [p-value=0.073] approached significance. Other conditions like HTN, DM, CVD, AI diseases, CKD and smoking history were not statistically significant (Table 1).Table 1Conclusion: In our small cohort of patients with GAVE, we found CAD was strongly associated with GAVE in patients without cirrhosis when compared to those with cirrhosis, while PAD approached statistical significance. We are limited by the small sample, which likely lowered the power of our study. Further large sample sized studies could help elucidate the association between underlying vascular disease and GAVE.

Risk assessment in acute non-variceal upper GI bleeding: the AIMS65 score in comparison with the Glasgow–Blatchford score in a Scottish population

IntroductionThe early use of risk stratification scores is recommended for patients presenting with acute non-variceal upper gastrointestinal (GI) bleeds (ANVGIB). AIMS65 is a novel, recently derived scoring system, which has...

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding

Objective. Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days. Materials and methods. Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates. Results. TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25–15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43–17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization. Conclusion. TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.