Rebleeding Rate In Patients Research Articles

The Risk of Re-Bleeding After An Index GI Bleed in Patients On Anticoagulation

Background: Anti-platelet and anticoagulation therapies have many medical indications and their use is very common. Previous studies have noted increased GI bleeding risks associated with different forms of anticoagulation and anti-platelet therapy. Less is known regarding risks of re-bleeding in patients who remain on anticoagulation and anti-platelet therapies after their incident GI bleed. Aim: To determine the impact of different types of anti-platelet and anticoagulation therapies on re-bleeding rates in patients who have already had a GI bleed.

Prospective, Randomized Trial Comparing Effect of Oral Versus Intravenous Pantoprazole on Rebleeding After Nonvariceal Upper Gastrointestinal Bleeding: A Pilot Study

Proton pump inhibitors (PPIs) reduce the rate of rebleeding in patients with nonvariceal upper GI bleed (NVGIB). Oral (PO) and intravenous (IV) pantoprazole are equipotent in raising gastric pH. We conducted a pilot study comparing the efficacy of PO vs. IV pantoprazole for reducing rebleeding after NVGIB. Patients with NVGIB were randomized to receive PO (80 mg BID for 3 days) or IV (80-mg IV bolus and 8 mg/hr infusion for 3 days) pantoprazole followed by pantoprazole, 40 mg PO BID, for 30 days. All patients underwent endoscopy within 24 hr and endotherapy was applied where necessary. Twelve patients randomized to the PO and 13 to the IV pantoprazole group were comparable in age, hematocrit, Rockall scores, ulcer characteristics, and endoscopic interventions. Two patients in the IV arm rebled and another in the IV arm developed reversible renal failure. No patient in the PO arm rebled, had organ failure, or had to be changed to IV pantoprazole. We conclude that in this pilot study, the effect of PO pantoprazole on 30-day rebleeding rate in patients with NVGIB was similar to that of IV pantoprazole.

Pre‐endoscopic proton pump inhibitor therapy reduces recurrent adverse gastrointestinal outcomes in patients with acute non‐variceal upper gastrointestinal bleeding

Proton pump inhibitors (PPIs) following endoscopic haemostasis reduce rebleeding rates in patients with high-risk acute non-variceal upper gastrointestinal bleeding. Many advocate the use of PPIs prior to endoscopy, although its incremental benefit is unproven. To determine if providing PPIs before endoscopy reduces adverse gastrointestinal outcomes in acute non-variceal upper gastrointestinal bleeding patients. We performed a retrospective review to identify patients presenting to two tertiary care centres with acute non-variceal upper gastrointestinal bleeding between 1999 and 2004. Subjects receiving PPI therapy before endoscopy were compared with those not receiving pre-endoscopic PPI therapy. The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality, readmission within 30 days for acute non-variceal upper gastrointestinal bleeding). 385 patients were included in our study [132 (12 intravenous/120 po) pre-endoscopic PPI vs. 253 no pre-endoscopic PPI]. Patients receiving pre-endoscopic PPI therapy were significantly less likely to develop adverse outcomes compared with those not given pre-endoscopic PPIs (25% vs. 13%, P = 0.005). Rebleeding, upper gastrointestinal surgery, mortality and length of hospital stay were also significantly lower in patients receiving pre-endoscopic PPI. The use of PPIs before endoscopy significantly reduces the risk of developing adverse gastrointestinal outcomes in patients with acute non-variceal upper gastrointestinal bleeding. Future studies are required to better characterize this relationship.

A comparison of oral omeprazole and intravenous cimetidine in reducing complications of duodenal peptic ulcer

BackgroundGastrointestinal bleeding is a common problem and its most common etiology is peptic ulcer disease. Ulcer rebleeding is considered a perilous complication for patients. To reduce the rate of rebleeding and to fasten the improvement of patients' general conditions, most emergency departments in Iran use H2-blockers before endoscopic procedures (i.e. intravenous omeprazole is not available in Iran). The aim of this study was to compare therapeutic effects of oral omeprazole and intravenous cimetidine on reducing rebleeding rates, duration of hospitalization, and the need for blood transfusion in duodenal ulcer patients.MethodsIn this clinical trial, 80 patients with upper gastrointestinal bleeding due to duodenal peptic ulcer and endoscopic evidence of rebleeding referring to emergency departments of Imam and Sina hospitals in Tabriz, Iran were randomly assigned to two equal groups; one was treated with intravenous cimetidine 800 mg per day and the other, with 40 mg oral omeprazole per day.ResultsNo statistically significant difference was found between cimetidine and omeprazole groups in regards to sex, age, alcohol consumption, cigarette smoking, NSAID consumption, endoscopic evidence of rebleeding, mean hemoglobin and mean BUN levels on admission, duration of hospitalization and the mean time of rebleeding. However, the need for blood transfusion was much lower in omeprazole than in cimetidine group (mean: 1.68 versus 3.58 units, respectively; p < 0.003). Moreover, rebleeding rate was significantly lower in omeprazole group (15%) than in cimetidine group (50%) (p < 0.001).ConclusionThis study demonstrated that oral omeprazole significantly excels intravenous cimetidine in reducing the need for blood transfusion and lowering rebleeding rates in patients with upper gastrointestinal bleeding. Though not statistically significant (p = 0.074), shorter periods of hospitalization were found for omeprazole group which merits consideration for cost minimization.

Transjugular Intrahepatic Portosystemic Shunts: Adjunctive Embolotherapy of Gastroesophageal Collateral Vessels in the Prevention of Variceal Rebleeding

To prospectively compare rebleeding rates in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) creation alone and those treated with TIPS creation combined with adjunctive embolotherapy of gastroesophageal collateral vessels. Informed consent and ethics committee approval were obtained. Between November 1991 and November 2002, the authors prospectively followed up 95 consecutive patients (61 men, 34 women; age range, 30-81 years) with variceal bleeding due to cirrhosis and portal hypertension. The patients were divided into two groups on the basis of splenoportographic findings after TIPS creation. The patients were treated with TIPS alone (group 1, 42 patients) or in combination with variceal embolotherapy (group 2, 53 patients). Embolotherapy with sclerosing agents in combination with coils was performed when varices continued to fill and the pressure gradient was more than 12 mm Hg. Rebleeding was defined as any hemorrhage necessitating a transfusion of 2 or more units of blood. Estimates for the cumulative patency, survival, and rebleeding rates were calculated by using life-table analysis; the log-rank test was used to compare the two treatment modalities. The prognostic relevance of treatment and selected variables with respect to rebleeding and survival were analyzed with multiple logistic regression. Mean follow-up time (+/- standard deviation) was 48.7 months +/- 37.8 (range, 1-127 months). The proportion of patients (Kaplan-Meier estimation) with TIPS who remained free of bleeding was 61% after 2 years and 53% after 4 years. Patients who underwent both the TIPS procedure and embolotherapy remained free of bleeding in 84% of cases after 2 years and in 81% of cases after 4 years. With respect to the rebleeding rate, the difference between the groups was statistically significant (log-rank test, P = .02). Results of multiple logistic regression analysis showed that variceal embolotherapy significantly reduced the risk of rebleeding (Wald test, P < .001). The results suggest that TIPS and adjunctive embolotherapy of gastroesophageal collateral vessels significantly lower the rebleeding rate in comparison to TIPS alone.

Endoscopic variceal ligation of patients with liver cirrhosis and cirrhosis accompanied by hepatocellular carcinoma

Background: Rupture of esophageal varices with severe gastrointestinal hemorrhage is one of the most serious complications of liver cirrhosis (LC) and hepatocellular carcinoma (HCC) complicating LC. The present study looks at the success of hemostasis in LC and LC accompanied by HCC, the success of breaking the varices cluster and the rate of rebleeding in patients of LC subject to emergency ligation and prophylactic ligation.Methods: Seventy‐five patients were divided into three groups. Group 1: 30 patients with LC accompanied by HCC with digestive bleeding; group 2: 30 patients with LC with digestive bleeding; and group 3: 15 patients with LC with high risk of digestive bleeding from esophageal varices (with no medical history of digestive bleeding). Success of hemostasis 72 h after endoscopic variceal ligation (EVL) was that patients did not vomit blood nor produce black feces. The effectiveness of EVL for iradication of the variceal cluster was classified into three levels: good, fairly good and poor.Results: The hemostasis success in group 1 (LC accompanied by HCC) and group 2 (LC with digestive bleeding due to esophageal varices) was 73.3% and 93.4%, respectively. The success of breaking the varix cluster in group 2 (LC) and group 3 (LC with high risk of digestive bleeding and treated by prophylactic ligation) was 73.3% and 80%, respectively. The rate of rebleeding in group 2 and group 3 after 1 year was 20% and 13.3%, respectively.Conclusion: Endoscopic variceal ligation is a good technique for variceal hemostasis and eradication of the esophageal varices cluster.

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

Intravenous proton pump inhibitors: requiem for endoscopic therapy?

No Influence of Helicobacter Pylori and Previous NSAID/ASA Therapy on Early Rebleeding Rate in Patients with Peptic Ulcer Bleeding

Background: Endoscopic treatment of peptic ulcer bleeding is effective but early rebleeding occurs in 15-25% of treated patients. There is little information available about the influence of H. pylori infection and previous NSAID treatment on the acute rebleeding rate in peptic ulcer bleeding. Aim: In our prospective study we investigated, whether H. pylori infection or previous NSAID medication can influence the early rebleeding rate in bleeding peptic ulcer after achieving initial haemostasis. Method and patients: Previous NSAID and/or ASA treatments were checked on the basis of medical history evaluated NSAID/ASA positive those who were taking this medication more than two days during the week before the bleeding started. H. pylori status was evaluated by rapide urease test and/or histology. Biopsies were taken during initial and/or second look endoscopies. Intravenous PPI (pantoprazole 8 mg/h) was administrated for 72 hours in every case but no patient received eradication therapy. A total of 292 patients were analysed after successful initial endoscopic treatment (duodenal ulcer: 189, gastric ulcer: 103). Results: Rebleedings within the first 72 hours occurred in 14.7% of DU patients and 11.8% of GU patients. Rebleeding rates in the NSAID/ASA user and non-user groups were 12.1% versus 14.6%, while in the H. pylori positive and negative patients 11.9% versus 15.6%. Interestingly only 3% of the H. pylori positive and NSAID/ASA treated patients re-bled, while the rebleeding rate among H. pylori negative non-NSAID/ASA patients was 16.2%. Conclusion: According to our results neither H. pylori infection, nor previous NSAID treatment are risk factors for early rebleeding during 72 hours in ulcer patients after successful initial haemostasis.

Comparison of oral omeprazole and endoscopic ethanol injection therapy for prevention of recurrent bleeding from peptic ulcers with nonbleeding visible vessels or fresh adherent clots

OBJECTIVES: Omeprazole is a potent inhibitor of gastric acid secretion. Recently it was reported that p.o. omeprazole therapy reduced the rebleeding rate in patients with nonbleeding visible vessels or adherent clots. The aim of this study was to ascertain whether p.o. administration of omeprazole can be an effective alternative to endoscopic injection therapy in peptic ulcers with stigmata of recent hemorrhage. METHODS: A total of 101 patients who had peptic ulcer bleeding based on endoscopic findings of nonbleeding visible vessels or fresh adherent clots were randomly assigned to receive omeprazole (40 mg p.o. every 12 h) or endoscopic ethanol injection therapy. RESULTS: Rebleeding rates were 22.9% (11 of 48) in the omeprazole group and 20.8% (11 of 53) in the endoscopic injection therapy group. The rebleeding rates of clinical significance were 14.6% and 13.2%, respectively. There was no significance difference in the rebleeding rate, requirement for surgery, total units of blood transfused, or mortality between the two groups. CONCLUSIONS: Oral omeprazole administration is comparable to endoscopic ethanol injection therapy for prevention of rebleeding in patients with nonbleeding visible vessels or adherent clots.

Esophageal Varices: TIPS or Ligation. What Is Your Final Answer?

ARTICLE SUMMARY A randomized study was conducted comparing two-year survival and rebleeding rates in patients with liver cirrhosis (Child-Pugh score 12 or less) receiving either transjugular intrahepatic portosystemic shunt (TIPS) (n=41) or serial endoscopic variceal ligation (EVL) (n=39) after initial control of bleeding. Patients with fundal varices were excluded. There was no difference in the two-year rates of survival between the groups (57% in the TIPS group compared with 56% in the EVL group), whereas the two-year rebleeding rates were 18.5% in the TIPS group and 66% in the EVL group (P<0.001). No patient who received TIPS suffered uncontrolled bleeding, whereas 11 banded patients had uncontrolled bleeding – of whom eight underwent emergency TIPS and the remaining three died. There was no difference in the rates of encephalopathy at two years between the two groups (44% in the TIPS group, 47% in the EVL group). Likewise, the numbers of days spent in hospital were similar between the two groups, both during the index bleed and over two years. The probability of shunt dysfunction in the TIPS group was 73% at two years.

Will Helicobacter pylori affect short-term rebleeding rate in peptic ulcer bleeding patients after successful endoscopic therapy?

OBJECTIVE: Helicobacter pylori ( H. pylori) can augment the pH-increasing effect of omeprazole in patients with peptic ulcer. A high intragastric pH may be helpful in preventing recurrent hemorrhage by stabilizing the blood clot at the ulcer base of bleeding peptic ulcer patients. Therefore, we hypothesized that omeprazole may reduce short-term rebleeding rate in these patients with H. pylori infection after initial hemostasis had been obtained. METHODS: Between July 1996 and December 1998, 65 bleeding peptic ulcer patients (24 gastric ulcer, 41 duodenal ulcer) who had obtained initial hemostasis with endoscopic therapy were enrolled in this trial. Thirty (46.2%) of them were found to have H. pylori infection by a rapid urease test and pathological examination. For all studied patients, omeprazole was given 40 mg intravenously every 6 h for 3 days. Thereafter, omeprazole was given 20 mg per os ( p.o.) once daily for 2 months. A pH meter was inserted in the fundus of each patient under fluoroscopic guidance after intravenous omeprazole had been administered. The occurrence of rebleeding episode was observed for 14 days. RESULTS: In patients with H. pylori infection, intragastric pH (median, 95% confidence interval [CI]: 6.54, 5.90–6.68) was higher than in those without H. pylori infection (6.05, 5.59–6.50, p < 0.001). However, the patients with rebleeding (2 vs 3), volume of blood transfusion (median, range: 1000 ml, 0–2250 vs 750, 0–2000), number of operations (0 vs 1), mortality caused by bleeding (0 vs 0), and hospital stay (median, range: 6 days, 3–14 vs 7, 5–16) were not statistically different from those without H. pylori infection. CONCLUSIONS: Omeprazole does increase intragastric pH in bleeding peptic ulcer patients with H. pylori infection. However, the presence of H. pylori infection does not affect the short-term rebleeding rate in these patients.

Helicobacter pylori and complicated ulcer disease.

Approximately 20-25% of patients with peptic ulcer disease develop complications--bleeding, perforation, or obstruction. Although the majority of patients with complicated ulcers are infected with Helicobacter pylori, the prevalence of infection appears to be lower in these patients compared with patients with uncomplicated ulcers. Among patients who present with a bleeding ulcer, approximately one-third will develop recurrent bleeding in the following 1-2 years if left untreated after ulcer healing. A number of studies have shown that the recurrence of rebleeding is virtually abolished if patients receive H. pylori eradication therapy. In contrast, the rate of rebleeding in patients receiving maintenance antisecretory therapy is around 10%. Thus, H. pylori infection status must be determined in patients presenting with complicated ulcer disease and, if positive, eradication therapy initiated. Eradication should be documented at least 4 weeks after the end of therapy (by endoscopic biopsy or urea breath test) and maintenance antisecretory therapy discontinued if the infection is cured.