Recent Hemorrhage Research Articles

ID: 3518653 UTILITY OF GEL IMMERSION METHOD FOR TREATING MASSIVE COLONIC DIVERTICULAR BLEEDING

In Asia, right-sided diverticular bleeding is more common than that of the left side. It often causes massive bleeding and difficulties in identifying the stigmata of recent hemorrhage (SRH) of colonic diverticular bleeding (CDB). This case series demonstrates the efficacy of the gel immersion method using OS-1 Jelly in patients with CDB.

Delayed anticoagulation in venous thromboembolism: Reasons and associated outcomes

ObjectiveWe assessed the number of cases with delayed anticoagulation initiation, explored the reasons for the delay, and its impact on outcome in patients with acute venous thromboembolism (VTE) treated in an organized setting of treatment initiation and continuous, prospective follow‐up. MethodsPatients with anticoagulation initiation delay >24 hours were identified within the cohort of patients with acute VTE enrolled in the Mayo Clinic Venous Thromboembolism Registry between 2013 and 2020. The reasons for treatment delay were explored by reviewing the electronic database. VTE recurrence, all‐cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared to those with no anticoagulation delay. ResultsOf 2378 patients with acute VTE, 100 (4.2%) experienced an anticoagulation delay. We identified seven reasons for treatment delays: deferring anticoagulation initiation to specialists (n = 38), thrombocytopenia (n = 10), planned or recent procedure (n = 16), active or recent bleeding (n = 12), missed diagnosis (n = 7), logistics (n = 6), and patient decision (n = 4). In seven cases, no reason was identified. We identified modifiable reasons for anticoagulation delay in 55%. At 90‐day follow‐up, patients with anticoagulation delay had a higher rate of mortality and major bleeding. VTE recurrence and CRNMB were not statistically different compared to those without anticoagulation delay. After adjustment for age, weight, and cancer, hazard ratios (HRs) for VTE recurrence and major bleeding remained elevated but not to a statistically significant level. ConclusionIn the setting of a highly organized system of anticoagulation initiation, the incidence of treatment delay is low. Yet most delays could be avoided. A low number of cases provide insufficient power to evaluate the clinical consequences of anticoagulation initiation delay; however, elevated HR for VTE recurrence and major bleeding suggest association and need for further investigation.

Argon plasma coagulation of the papilla of Vater for treatment of a Dieulafoy lesion.

A 54-year-old man was admitted to the emergency room for a syncope episode and melena. The laboratory test highlighted a hemoglobin of 6.8 g/dL, and 2 blood transfusions were performed. An upper endoscopy revealed stigmata of recent bleeding in the duodenum, and active bleeding was visualized at the level of the major papilla. Therefore, hemobilia or hemosuccus pancreaticus was suspected. An abdominal computed tomography (CT) scan did not reveal any underlying biliopancreatic disorder.

Early colonoscopy and urgent contrast enhanced computed tomography for colonic diverticular bleeding reduces risk of rebleeding.

BACKGROUNDColonoscopy within 24 h of hospital admission for colonic diverticular bleeding (CDB) is recommended. However, little is known about rates of rebleeding within 30 d. We posited that a group of patients who underwent contrast-enhanced computed tomography (CT) within 4 h of the last hematochezia and colonoscopy within 24 h would experience fewer incidences of rebleeding.AIMTo evaluate the outcomes of early colonoscopy for CDB among different groups of patients.METHODSData from 182 patients with CDB who underwent contrast-enhanced CT and colonoscopy between January 2011 and December 2018 at the study site were retrospectively reviewed. Patients were divided into groups based on the timing of the CT imaging, within or at 4 h were defined as urgent CTs (n = 100) and those performed after 4 h were defined as elective CTs (n = 82). Main outcomes included rebleeding within 30 d and the identification of stigmata of recent hemorrhage (SRH) (i.e., active bleeding, non-bleeding visible vessels, or adherent clots).RESULTSIn total, 182 patients (126 men and 56 women) with median ages of 68.6 (range, 37-92) and 73.7 (range, 48-93) years, respectively, underwent CT imaging and colonoscopy within 24 h of the last hematochezia. Patients for whom CT was performed within 4 h of the last hematochezia were included in the urgent CT group (n = 100) and patients for whom CT was performed after 4 h were included in the elective CT group (n = 82). SRH were identified in 35.0% (35/100) of the urgent CT cases and 7.3% (6/82) of the elective CT cases (P < 0.01). Among all patients with extravasation-positive images on CT, SRH was identified in 31 out of 47 patients (66.0%) in the urgent CT group and 4 out of 20 patients (20.0%) in the elective CT group (P < 0.01). Furthermore, rates of rebleeding within 30 d were significantly improved in the urgent CT and extravasation-positive cases (P < 0.05). Results from the evaluation of early colonoscopy did not show a difference in the ability to detect SRH identification or rebleeding rates. Only cases by urgent CT reduced risk of rebleeding due to the evidence of active bleeding on the image.CONCLUSIONTo improve rates of rebleeding, colonoscopy is recommended within 24 h in patients with extravasation-positive CT images within 4 h of the last hema-tochezia. Otherwise, elective colonoscopy can be performed.

Timing of Colonoscopy and Factors Indicating Early Colonoscopy in Acute Lower Gastrointestinal Bleeding: A Large-Scale Multicenter Cohort Study

Background: Optimal timing of colonoscopy for acute lower gastrointestinal bleeding is controversial, and it is unclear which patients benefit from early colonoscopy. The reported proportion of hemodynamically unstable patients is lower in randomized controlled trials than in observational studies. Methods: We studied 6,311 patients admitted for acute hematochezia in 49 Japanese hospitals, named the CODE-BLUE J Study. One propensity score-matched cohort comprised patients who underwent early (<24 hours) vs. non-early (24–96 hours) colonoscopy; the other comprised elective (24–48 hours) vs. late (48–96 hours) colonoscopy. Interaction term models were used to identify characteristics of patients who benefited from early colonoscopy. Findings: We compared 1,960 pairs of early vs. non-early patients. The early group showed higher rates of identification of stigmata of recent hemorrhage (SRH), endoscopic hemostasis (31% vs. 18%, P<0·001), and 30-day rebleeding, and a shorter length of hospital stay. The interventional radiology (IVR)/surgery rate was marginally lower in the early cohort (1·1% vs. 1·8%, P=0·083). Thirty-day mortality and blood transfusion rates were not significantly different between the groups. Of 810 pairs of elective vs. late patients, the elective group had a higher rate of SRH identification and shorter length of hospital stay. Systolic blood pressure (SBP) ≤100 mmHg at admission modified the qualitative effect of timing (early vs non-early) on requirement for IVR/surgery (odds ratio: 2·58 [95% confidence interval: 1·00–6·66] vs 0·98 [0·55–1·40]; P for interaction=0·047). Interpretation: Early colonoscopy increased the rates of SRH identification and endoscopic hemostasis and reduced the length of hospital stay but did not improve rebleeding and mortality. Early colonoscopy benefited patients with low SBP at presentation. Funding Information: This work was partially supported by grants from the Ministry of Health, Labour and Welfare, JSPS (KAKENHI), Smoking Research Foundation, Takeda Science Foundation, and National Center for Global Health and Medicine. Declaration of Interests: The authors have no relevant conflicts of interest to declare. Ethics Approval Statement: Approval from the ethical committees and institutional review boards of all 49 participating hospitals was obtained using the opt-out method. The requirement for patient consent was waived considering the retrospective nature of the study.

EFFECT OF HELICOBACTER PYLORI INFECTION ON NON VARICEAL BLEEDING IN PATIENTS WITH LIVER CIRRHOSIS

Background: Variceal bleeding in chronic liver disease has been studied extensively. However, 30-40% of upper digestive hemorrhages in cirrhotic patients are non variceal (NVUGIB). Clinical features and endoscopic findings of this population have rarely been reported. Objective: To determine the prevalence of H. pylori infection in cirrhotic patients with non variceal upper gastrointestinal bleeding. Patients and methods: This was carried out at Hepatology, Gastroenterology and Infectious Diseases Department of Al-Azhar University Hospitals, and conducted on 150 patients infected by H. pylori From May 2019 till November 2019. Pateints were selected and divided into three equal groups: Group A: Patients with recent active bleeding (maximum within two days) of non variceal origin diagnosed endoscopically. Group B Matched cirrhotic patients without history of upper gastrointestinal bleeding, and group C Non-cirrhotic patients without history of upper gastrointestinal bleeding. Upper GI Endoscopy was done for all patients of the studied groups. Multiple biopsies were taken and H.pylori infection was determined by Histopathology. Results: The mean age of participants was 54.3 years. Males were 79 (52.6%) while females were 71 (47.3%). 58 of 150 patients (38.6%) were positive for H. pylori. there was no significant relation between H. pylori positivity and cause of cirrhosis. there was significant relation between H. pylori positivity and Sex of the studied cases. And there was high significant difference between the studied groups as regard H. pylori distribution. Conclusion: There was significant association between H. pylori infection and non variceal upper gastrointestinal bleeding. Eradication therapy has a role in reducing the incidence of NVUGIB in cirrhotic patients.

POS-751 AN UNUSUAL PRESENTATION OF ARTERI-VENOUS FISTULA AFTER RENAL BIOPSY: CASE REPORT

Renal biopsy is an important diagnostic procedure but is associated with a number of significant complications even when performed by a skilled operator. While most of these complications present with haemodynamic disturbance, pain or macroscopic haematuria, some – such as the development of a post-biopsy arteriovenous fistula may be occult. We present an unusual presentation of a post-biopsy arteriovenous fistula which was diagnosed after the patient reported an audible bruit. A 39-year-old woman with end stage renal disease of unknown etiology received her first kidney transplant in February 2020. The right kidney from a deceased after cardiac death donor was transplanted into her right iliac fossa. Before transplantation, she had been on hemodialysis via an arteriovenous fistula (AVF) for a year. There was delayed graft function and the patient was dialysed through her AVF on the 2nd day of transplantation. Graft function was slow to improve and a kidney biopsy was performed on the 6th day post-transplantation. The biopsy was performed under ultrasound (US)control with two passes of a 16 G needle. Post-procedure observations were unremarkable and the patient went home after 6 hours of bed rest.The biopsy showed borderline rejection and the patient was prescribedthree doses of intravenous methylprednisolone. On the second day post-biopsy, graft function remained poor and routine bloods showed a drop in haemoglobin from 107 to 78 g/L. Abdominal US did not show any abnormality. Patient received blood transfusion and was observed overnight. The patient was discharged home next day. On the 5th day post-biopsy, the patient presented with reports of hearing “buzzing” sounds. ENT review was unremarkable. Graft function was poor and the patient remained on dialysis. Abdominal US and Doppler studies showed a large AVF within the transplanted kidney at the site of the earlier biopsy (fig 1). Figure 1: Doppler ultrasound of renal transplant showing post biopsy AVF The fistula was large and, with evidence of recent bleeding, thus underwent coil embolisation in the interventional radiology department (fig 2). Figure 2: Coil embolisation of AVF. Left panel shows initial angiographic appearance; right panel shows appearance following coil embolisation At present, the patient is nine months post-transplantation and remains dialysis independent with stable graft function and an eGFR 25-30 mL/min/1.73m2. Most biopsy-associated AVFs close spontaneously, are asymptomatic, and do not require intervention. The indication for intervention is usually an increase in the size of fistula over time, the development of signs of heart failure, deterioration in kidney function, or a rise in blood pressure. Embolisation of biopsy-associated AVFs has been reported to result in good outcomes with minimal changes in serum creatinine and estimated glomerular filtration rate. The risks include proximal dissemination of the embolisation material and the resultant focal occlusion of the arterial system causing renal, gut and pulmonary ischaemia. Surgical procedures are reserved for large AVFs with high velocity flows. Complications of kidney biopsy can be asymptomatic, and missed because of late and atypical presentation. A possibility of kidney biopsy related complication should always be considered when a patient presents within few weeks of the kidney biopsy.

Risk factor analysis for early rebleeding after endoscopic treatment for colonic diverticular bleeding with stigmata of recent hemorrhage.

Background and AimColonic diverticular bleeding is a common cause of acute lower gastrointestinal bleeding. Endoscopic hemostasis is generally selected as the first‐line treatment; however, a considerable number of patients experience early rebleeding after endoscopic treatment. We investigated the risk factors for early rebleeding after endoscopic treatment.MethodsWe retrospectively evaluated the data of 142 consecutive patients who underwent endoscopic treatment (endoscopic clipping or endoscopic band ligation) for colonic diverticular bleeding with stigmata of recent hemorrhage between April 2012 and April 2020. Multivariate logistic regression analysis was conducted to evaluate the statistical relationship between patient characteristics and the incidence of early rebleeding occurring within 30 days after endoscopic treatment.ResultsOf 142 patients, early rebleeding was detected in 34 (23.9%) patients. According to univariate analysis, platelet count of <10 × 104/μL, bleeding from the left‐sided colon, and endoscopic clipping usage were associated with early rebleeding (P < 0.05). The subsequent multivariate logistic regression analysis identified bleeding from the left‐sided colon (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.73–10.0; P = 0.001) and endoscopic clipping usage (OR, 2.92; 95% CI, 1.21–7.00; P = 0.017) as the independent risk factors for early rebleeding.ConclusionsBleeding from the left‐sided colon and endoscopic clipping usage were the risk factors for early rebleeding after endoscopic treatment. Using endoscopic band ligation was associated with a decreased risk for early rebleeding compared with the use of endoscopic clipping, indicating that endoscopic band ligation was a preferable endoscopic modality to prevent early recurrent bleeding.

THE RISK OF CEREBRAL MICROBLEEDS IN ISCHEMIC STROKE PATIENTS USING ANTIPLATELET THERAPIES

Background: Interest in cerebral microbleeds (CMBs) has increased based on advances in magnetic resonance imaging (MRI) technology. Both MRI T2-weighted gradient-echo (GRE) and susceptibility-weighted imaging may be sensitive techniques for the detection of past and more recent brain hemorrhage. The prevalence of CMBs in healthy population ranges 3.7–7.7%, whereas in patients with intracerebral hemorrhage is thought to be around 60%.Objective: To evaluate the prevalence and possible risk of microbleeds among patients with ischemic stroke using antiplatelets (Aps).Patients and Methods: The observational hospital-based cross-sectional analytical study involved 150 consecutive patients with ischemic stroke (recent or old ischemic strokes or both), from inpatients of neurology departments of Ain Shams University Hospital and Agouza Police Hospital for a period of 15 months from April 2018 to June 2019.Results: Cerebral microbleeds were present in 13 patients representing 26% of the no AP group, 16 patients representing 32% of the single AP group and 19 patients representing 38% of the double AP group, there was no statistically significant difference between the three groups of patients. Cerebral microbleeds were present in 60% of patients on double APs and 37.5% of patient on single AP for more than two years, compared to 23.3%and 26.9%for the two groups respectively on APs for less than two years, In the current study we found that the significant risk factor for the presence of CMBs was the duration of APs use. There was no statistically significant difference in the laboratory data (including full lipid profile, HbA1c and platelet count) between the three groups.Conclusion: CMBs are significantly associated with long term use of antiplatelets, so careful clinical and radiological follow up of ischemic stroke patients with CMBs using antiplatelets for risk of future intracranial hemorrhage.

A Roadmap for Developing Plasma Diagnostic and Prognostic Biomarkers of Cerebral Cavernous Angioma With Symptomatic Hemorrhage (CASH)

Cerebral cavernous angioma (CA) is a capillary microangiopathy predisposing more than a million Americans to premature risk of brain hemorrhage. CA with recent symptomatic hemorrhage (SH), most likely to re-bleed with serious clinical sequelae, is the primary focus of therapeutic development. Signaling aberrations in CA include proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammatory/immune processes, and anticoagulant vascular domain. Plasma levels of molecules reflecting these mechanisms and measures of vascular permeability and iron deposition on magnetic resonance imaging are biomarkers that have been correlated with CA hemorrhage. To optimize these biomarkers to accurately diagnose cavernous angioma with symptomatic hemorrhage (CASH), prognosticate the risk of future SH, and monitor cases after a bleed and in response to therapy. Additional candidate biomarkers, emerging from ongoing mechanistic and differential transcriptome studies, would further enhance the sensitivity and specificity of diagnosis and prediction of CASH. Integrative combinations of levels of plasma proteins and characteristic micro-ribonucleic acids may further strengthen biomarker associations. We will deploy advanced statistical and machine learning approaches for the integration of novel candidate biomarkers, rejecting noncorrelated candidates, and determining the best clustering and weighing of combined biomarker contributions. With the expertise of leading CA researchers, this project anticipates the development of future blood tests for the diagnosis and prediction of CASH to clinically advance towards precision medicine. The project tests a novel integrational approach of biomarker development in a mechanistically defined cerebrovascular disease with a relevant context of use, with an approach applicable to other neurological diseases with similar pathobiologic features.

Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis.

There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. Of 114 RE patients, the mean age was 61.1years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.

Presigmoid Transpetrosal Approach for Superficial Temporal Artery to Distal Posterior Cerebral Artery Bypass and Trapping of Aneurysm.

BACKGROUND AND IMPORTANCEAneurysms of the posterior cerebral artery (PCA) are uncommon, estimated at less than 1% of all cerebral aneurysms, and less than half occur distal to the P1/2 junction. Unfortunately, the conventional bypass approach for PCA aneurysms—primarily occipital artery to distal PCA cortical branches—has a history of unsatisfying results.CLINICAL PRESENTATIONA 42-yr-old female presented with Fisher 3 Hunt-Hess 2 subarachnoid hemorrhage secondary to ruptured distal PCA aneurysm. She was initially evaluated by the endovascular service, but due to recent subarachnoid hemorrhage, endovascular treatment with flow diversion and/or vessel sacrifice was felt to be relatively contraindicated and the patient was referred for surgical evaluation for possible bypass. The patient subsequently underwent surgery for trapping of aneurysm and concomitant superficial artery to distal PCA bypass.CONCLUSIONA novel approach for the treatment of a ruptured distal PCA aneurysm is described, consisting of posterior transpetrosal exposure and division of the tentorium with superficial temporal artery to P3 bypass.

Re-bleed and Mortality Amongst Patients Following Initial Endoscopy for Upper Gastrointestinal Bleeding: A Single-Center Nigeria Study.

Background and aimClinical and endoscopic parameters are predictive of patient outcome following acute upper gastrointestinal bleeding. The study aimed to investigate factors related to re-bleed and mortality following initial endoscopy among Nigerian patients with recent upper gastrointestinal bleeding (UGIB).MethodsThis is a cohort study of patients undergoing endoscopy for recent-onset UGIB at a referral endoscopy facility in Port Harcourt, Rivers State, Nigeria, from April 2014 to November 2020. Patients’ demographic and clinical data, American Society of Anesthesiologists (ASA) physical status, amount of blood transfusion, endoscopy results, and Rockall scores were retrieved from patients’ charts. The re-bleed and mortality rates were noted on follow-up by telephone. Statistical analysis was performed using SPSS version 20 (IMB Inc., Armonk, USA).ResultsA total of 560 patients had flexible video oesophagogastroduodenoscopy during the study period, and 46 (8.2%) of these were included in the study. Their age ranged from 28 years to 84 years (mean 58.6 ± 15.8 years) with 32 (69.6%) males and 14 (30.4%) females. Peptic ulcer disease (PUD) and gastritis/gastric erosions were the leading endoscopic diagnoses in 24 (52.2%) and 12 (26.1%) patients, respectively. Multiple comorbidities (p=0.021) and higher ASA score (mean 3.0; 95% confidence interval CI: 2.47-3.53; p=0.021) are associated with re-bleed, which was recorded in seven (15.2%) patients. Four (8.7%) cases of mortality were recorded in patients with a mean full Rockall score of 4.25 (95% CI: 1.52-6.97; p=0.021).ConclusionRe-bleed is more common in patients with multiple comorbidities, ASA score of three or more, and bleeding gastro-oesophageal varices at initial endoscopy. Mortality was significantly higher in patients with a full Rockall score of more than three.

Transient congenital Horner syndrome and multiple peripheral nerve injury: a scarcely reported combination in birth trauma

Abstract Objectives To describe an infrequent association of multiple injuries in relation to perinatal trauma and the challenge of clinical examination for proper diagnosis. Case presentation A male newborn was born at 41 weeks gestational age to a multipara diabetic mother, by forceps. Apgar 8/9. Upon admission, he exhibited axial hypotonia, right brachial paresis, a large left parietal cephalohematoma, but no skull fractures or orbital injuries. He also showed ocular misalignment with marked esotropia of the right eye, ptosis and mild anisocoria, suggesting right Horner syndrome, and left facial palsy. During the oculo-cephalic reflex examination he exhibited a normal adduction and impaired abduction of the right eye. The cranial MRI showed an extensive left parietal cephalohematoma, with internal foci of recent bleeding, and supra and infratentorial laminar subdural hematomas. No lesions were evidenced in the cavernous sinuses. The recovery of extra and intraocular motility at one month of life in our patient highlighted the transitory nature of the lesions and was reassuring for the parents. Conclusions This case highlights the importance of a detailed clinical examination in the initial evaluation of a newborn at neurological risk after birth trauma. The association of sixth cranial nerve palsy, Horner syndrome, facial palsy, and brachial plexus injury have been scarcely referred in this context and, if not adequately interpreted, might suggest erroneous diagnoses with very different prognoses.

A New Score for Predicting Acute Gastrointestinal Bleeding in Patients Administered Oral Antiplatelet Drugs.

Antiplatelet drugs may increase the risk of gastrointestinal bleeding. Currently, there is no specific score for predicting the risk of gastrointestinal bleeding caused by oral antiplatelet drugs. In this study, the gastrointestinal bleeding risk score was established and compared with the CRUSADE score in order to reduce the occurrence of clinical gastrointestinal bleeding events. Our study included 4052 patients who received oral antiplatelet drugs. Data were obtained from the patient medical records inpatient system. Cases of acute gastrointestinal bleeding and mortality were recorded. The bleeding score was established by logistic regression, area under the receiver operating characteristic curve, and the Hosmer–Lemeshow test. Finally, 171 patients had acute gastrointestinal bleeding. The mortality rates of patients in the bleeding and nonbleeding groups were 24.6 and 4.7%, respectively. A multivariate analysis revealed that an age of >65 years, anemia, recent major bleeding, a history of gastrointestinal bleeding, combined oral anticoagulants, and dual antiplatelet therapy are risk factors, and combined proton pump inhibitors are protective factors for acute gastrointestinal bleeding. We used these risk factors to establish a score for predicting acute gastrointestinal bleeding, named (ABC)2D score. The area under the curve for (ABC)2D score was 0.857 (p < 0.001), higher than the CRUSADE score of 0.693 (p < 0.001). The Hosmer–Lemeshow p value was 0.324. We developed the (ABC)2D score based on seven risk factors (i.e., age, anemia, recent major bleeding, a history of gastrointestinal bleeding, no-proton pump inhibitors use, combined oral anticoagulants, and dual antiplatelet therapy). (ABC)2D score was superior to the CRUSADE score. This new risk-scoring model may help to identify patients at a significant risk of gastrointestinal bleeding.

CLINICAL FEATURES OF GASTROINTESTINAL ULCERATIVE BLEEDING IN ELDERLY PATIENTS COMPLICATED BY CARDIO-VASCULAR PATHOLOGY

The aim: To determine clinical and endoscopical features of gastroduodenal hemorrhages in elderly patients with concomitant cardio-vascular pathology in a way by studying, main indicators of the immune system for drawing up further tactics. Material and methods: The study included 609 patients with ulcerative gastroduodenal bleeding, complicated by cardio-vascular system pathology in 2017-2019 years. The observed patients were distributed into the groups: I - patients, who received treatment according to the standard system of cardiovascular pathology treatment (n=541), II - "double" therapy (n=68). Control group consists of 20 relatively healthy patients were similar to the research group. Results: Blood lost of a big amount and massive blood lost were noticed in 113 (18.56%±1.58) and 121 (19.87%±1.62) patients respectively. Active bleeding (F I) was revealed in 38 patients (6.24%±0.98), a high risk of hemorrhage relapse was determined in 486 patients (79.80%±1.63). Signs of recent hemorrhage were absent in 85 patients (13.96%±1.40). A high level of pro-inflammatory cytokines IL-6, TNF-α and a low activity of the anti-inflammatory mediator IL-10 define the process activity, their long-term circulation in patients with ulcerative hemorrhages of the gastro-intestinal tract are associated with unfavorable prognosis. In 5 cases conditionally-radical surgical interventions were performed. Palliative surgery - 3 patients (р>0.05). Conclusions: The patients of second group ("double therapy") with big and massive blood loss was 2.7 times higher than similar indices in patients of the first group (standard therapy). The patients who received "double therapy" had 3.3 times more active hemorrhage percentage than the patients who received standard therapy (р<0.05).

Praziquantel and Upper Gastrointestinal Bleeding in Hepatic Schistosomiasis: A Quasi-Experimental Study.

BackgroundThere is a general consensus that widespread use of praziquantel in populations where schistosomiasis is endemic prevents development of hepatic schistosomiasis and its complications. However, a few studies have reported discordant findings linking praziquantel to the occurrence of upper gastrointestinal bleeding (UGIB) in some patients with hepatic schistosomiasis and varices.ObjectiveWe explored if there was any causal association between recent praziquantel use (rPZQ) and upper gastrointestinal bleeding in hepatic schistosomiasis in rural Africa.Patients and MethodsA quasi-experimental, retrospective case-controlled study was performed. It involved adult patients with past or acute UGIB, varices, periportal fibrosis, and/or cirrhosis. Cases had acute variceal bleeding while controls did not. The outcome was the frequency of lifetime episodes of UGIB and exposure was rPZQ (received praziquantel in the last 11 months from the date of enrollment). The data analysis included 2 × 2 tables, logistic regression, and propensity-score matching. Odds ratios (ORs), average treatment effects (ATEs), and their 95% confidence intervals (CIs) were used for inference.ResultsOver 6 weeks, we enrolled 19 cases with 92 lifetime episodes of UGIB, and 66 controls with 192 lifetime episodes of UGIB. Cases were more likely to experience UGIB than controls following rPZQ (92% vs. 62%; OR 7.6; 95% CI 3.4–17). Factors predictive of more lifetime episodes of UGIB at multivariable analysis included rPZQ (adjusted OR 13; 95% CI 2.9–53), relative leukocytosis (adjusted OR 26; 95% CI 7.6–89), large varices (adjusted OR 5.0; 95% CI 1.7–15), a family member with hepatosplenic schistosomiasis (adjusted OR 19; 95% CI 7.4–51), advanced periportal fibrosis (adjusted OR 8.0; 95% CI 2.6–22), ascites (adjusted OR 14; 95% CI 4.3–47), and jaundice (adjusted OR 32; 95% CI 7.8–128). While the ATE following rPZQ among the treated was 0.40 (95% CI 0.33–0.48).ConclusionsOur findings suggest the presence of a plausible causal association between recent praziquantel use and increased frequency of UGIB in our study population.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40801-020-00222-7.

Complex management of type 2 heparin-induced thrombocytopenia in patients with major bleeding tendency: two case report

Type 2 heparin-induced thrombocytopenia (HIT 2) is a rare pro-thrombotic disorder occurring in patients treated with heparin. It is defined as a clinical-biological syndrome associating the sudden onset of a thrombocytopenia, characterized by a drop of more than 50% of the initial platelet count, and thrombosis. We report two cases of HIT 2 occurring in patients with major bleeding tendency. The first HIT occurred in a patient whose management, in accordance with current guidelines, made it possible to control the thrombocytopenia and the anticoagulation despite the complexity of adapting and monitoring treatments in the context of recent cerebral hemorrhage. The second refers to an autoimmune HIT, which occurred in a patient whose management required the use of alternative therapies to the standard treatments suggested for HIT 2, to correct the severe refractory thrombocytopenia.

Abstract 15192: Effectiveness and Safety of Reduced Dose of Dabigatran for High Bleeding Risk Patient Subgroups With Atrial Fibrillation

Off-label reduced dosing of direct oral anticoagulants is common among patients at high bleeding risk with atrial fibrillation (AF), however, outcomes data of reduced dosing are limited. We evaluated the effectiveness and safety of reduced dose of dabigatran [110 mg twice daily (BID)] vs. standard dose [150 mg BID] in high bleeding risk subgroups with AF. We identified adult patients with AF who initiated dabigatran (index date) with creatinine clearance (CrCl) ≥30 mL/min between 2012-2018 from Kaiser Permanente Southern California. Three high bleeding risk subgroups were identified: 1) patients aged ≥80 years; 2) patients with moderate renal impairment (CrCl 30-49 mL/min) regardless of age; or 3) patients with bleeding within 12 months prior to the index date or HAS-BLED score ≥3. Patients were followed through December 2018 for stroke or systemic embolism, major bleeding requiring hospitalization, and all-cause mortality. Cause-specific hazard regression models were used to investigate associations between dabigatran dose and clinical outcomes adjusting for covariates and considering competing risks of death. Among high bleeding risk patients with AF [3,749 aged ≥80 years; 1,716 with moderate renal impairment; 3,051 with recent bleed or high HAS-BLED score], 34% received reduced dose of dabigatran. Patients who received reduced dose were older, had reduced renal function, and had more comorbidities. Compared with standard dose, reduced dose of dabigatran was not associated with an increased risk of stroke or systemic embolism but was associated with lower risk of major bleed in patients aged ≥80 years ( Table ). Reduced dose of dabigatran was also associated with lower risk of mortality among patients aged ≥80 years and patients with moderate renal impairment. A lower risk of bleeds and mortality associated with reduced vs standard dose of dabigatran in high-risk patients with AF suggest a better dosing strategy for these risk groups.

Abstract 14588: Post-discharge Readmission and Survival After Percutaneous Coronary Intervention Among Patients With a History of Recent Gastrointestinal Bleeding: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Introduction: Given the use of potent antithrombotic agents during and after PCI, patients (pts) are at an increased risk of gastrointestinal bleeding (GIB). Hypothesis: We hypothesize that pts with a history of recent GIB have a higher risk of post-discharge readmission and mortality compared with those without a history of GIB. Methods: We linked clinical registry data from PCIs performed between 1/1/2013 and 3/31/2018 at 48 Michigan hospitals to Medicare claims. A recent history of GIB prior to PCI was defined in the clinical PCI registry as any occurrence of melena or hematemesis in the last 30 days or any history of GIB including peptic ulcer disease that may influence clinical management during this hospitalization. Primary outcomes of interest were 90-day readmission after PCI and long-term mortality. We used 1:5 propensity-matching to adjust for differences in characteristics between pts with and without a history of recent GIB. Log-rank testing was used to evaluate survival at 1 and 5 years. Fisher's exact testing was used to compare the rates of 90-day readmission after PCI. Results: Of 30,206 pts, 1.1% had a history of GIB. Pts with a history of GIB were more likely to be older, female, black, and have more cardiovascular comorbidities. After matching 1896 pts, those with a history of GIB (n=316) appeared to have decreased survival early after PCI (Fig); however, the differences in survival were not statistically significant at 1 yr (76.%3 vs. 80.1%; p=0.11) or 5 yrs (52.5% vs. 52.2%; p=0.50) (Fig). There was no significant difference in readmission rates among those with and without a history of GIB (33.5% vs. 30.2%; p=0.26). Conclusions: Pts with and without a history of recent GIB had similar risks of readmission and long-term mortality after PCI. Although a history of GIB has previously been shown to be associated with increased post-PCI bleeding complications, a recent history of GIB was not associated with long-term post-PCI outcomes.