Risk Factors For Rebleeding Research Articles

Risk factors for early rebleeding and mortality in acute variceal hemorrhage.

To investigate the risk factors for 6-wk rebleeding and mortality in acute variceal hemorrhage (AVH) patients treated by percutaneous transhepatic variceal embolization (PTVE). A retrospective cohort study of AVH patients who had undergone PTVE treatment was conducted between January 2010 and December 2012. Demographic information, medical histories, physical examination findings, and laboratory test results were collected. The PTVE procedure was performed as a rescue therapy for patients who failed endoscopic and pharmacologic treatment. Survival analysis was estimated using the Kaplan-Meier method and compared using the log-rank test. The multivariate analysis was performed using the Cox regression test to identify independent risk factors for rebleeding and mortality. One hundred and one patients were included; 71 were males and the average age was 51 years. Twenty-one patients rebled within 6 wk. Patients with high-risk stigmata, PTVE with trunk obliteration, and a hepatic vein pressure gradient (HVPG) ≥ 20 mmHg were at increased risk for rebleeding (OR = 5.279, 95%CI: 2.782-38.454, P = 0.003; OR = 4.309, 95%CI: = 2.144-11.793, P < 0.001; and OR = 1.534, 95%CI: 1.062-2.216, P = 0.022, respectively). Thirteen patients died within 6 wk. A model for end-stage liver disease (MELD) score ≥ 18 and an HVPG ≥ 20 mmHg were associated with 6-wk mortality (OR = 2.162, 95%CI: 1.145-4.084, P = 0.017 and OR = 1.423, 95%CI: 1.222-1.657, P < 0.001, respectively). MELD score and HVPG in combination allow for early identification of patients with AVH who are at substantially increased risk of death over the short term.

Frequency and risk factors for rebleeding events in patients with small bowel angioectasia.

BackgroundSmall bowel angioectasia is reported as the most common cause of bleeding in patients with obscure gastrointestinal bleeding. Although the safety and efficacy of endoscopic treatment have been demonstrated, rebleeding rates are relatively high. To establish therapeutic and follow-up guidelines, we investigated the long-term outcomes and clinical predictors of rebleeding in patients with small bowel angioectasia.MethodsA total of 68 patients were retrospectively included in this study. All the patients had undergone CE examination, and subsequent control of bleeding, where needed, was accomplished by endoscopic argon plasma coagulation. Based on the follow-up data, the rebleeding rate was compared between patients who had/had not undergone endoscopic treatment. Multivariate analysis was performed using Cox proportional hazard regression model to identify the predictors of rebleeding. We defined the OGIB as controlled if there was no further overt bleeding within 6 months and the hemoglobin level had not fallen below 10 g/dl by the time of the final examination.ResultsThe overall rebleeding rate over a median follow-up duration of 30.5 months (interquartile range 16.5–47.0) was 33.8% (23/68 cases). The cumulative risk of rebleeding tended to be lower in the patients who had undergone endoscopic treatment than in those who had not undergone endoscopic treatment, however, the difference did not reach statistical significance (P = 0.14). In the majority of patients with rebleeding (18/23, 78.3%), the bleeding was controlled by the end of the follow-up period. Multiple regression analysis identified presence of multiple lesions (≥3) (OR 3.82; 95% CI 1.30–11.3, P = 0.02) as the only significant independent predictor of rebleeding.ConclusionIn most cases, bleeding can be controlled by repeated endoscopic treatment. Careful follow-up is needed for patients with multiple lesions, presence of which is considered as a significant risk factor for rebleeding.

Overt Gastrointestinal Bleeding and Predictors of Rebleeding in Hematologic Malignancies

Introduction: GI bleeding in patients with hematologic malignancies is not well studied. These patients tend to have lower platelet counts and/or dysfunctional platelets which are strong predisposing factors for bleeding distinguishing them from other groups. We aim to determine the various etiologies for GI bleeding and predictors of rebleeding in this group of patients. Methods: We performed a retrospective chart review of all individuals who underwent EGD and colonoscopy for overt bleeding between 2009 to 2011, at our institution. We studied the etiologies of GI bleeding and the incidence and risk factors for rebleeding among patients with hematologic malignancies. The study population was followed for rebleeding after their index bleeding episode. The predictors of rebleeding were determined using competing risk regression with death as a competing event. Results: The study population consisted of 79 patients with an index bleed, of which 50 underwent EGD and 44 underwent colonoscopy (15 had both). Amongst these, 13 (17%) had hematemesis, 31 (39%) had melena and 35 (44%) had hematochezia at presentation. The mean age of the patients was 61 years [58-64 at 95% CI], male:female ratio% was 57:43 and 72% were Caucasians. There were 40 patients with leukemia (51%), 28 with lymphoma (35%) and 11 with multiple myeloma (14%). The etiologies for bleeding have been described in tables 1 and 2. The median follow up time was 7.5 months (0.3 - 55.3) during which 16 patients had a rebleeding episode. The incidence of rebleeding was 1.2% [0.7-1.9 at 95% CI] per patient month. Patients with multiple myeloma were 3.5 times more likely to rebleed after adjusting for demographics, platelet count, INR and WBC count. Conclusion: In patients with hematologic malignancies, the presence of multiple myeloma and with underlying thrombocytopenia increases the risk of recurrent GI bleeding.Table 1: Etiology of Overt Gastrointestinal Bleeding Among Patients With Primary Hematologic Malignancies Who Underwent EGDTable 2: Etiology of Overt Gastrointestinal Bleeding Among Patients With Primary Hematologic Malignancies Who Underwent Colonoscopy

Incidence and predictors of rebleeding after band ligation of oesophageal varices

Background and study aimsVariceal bleeding is a severe complication in patients with portal hypertension. Early rebleeding occurs frequently in the first few weeks after band ligation, and the mortality associated with each bleeding episode ranges from 30% to 50%. Our aims were to study the rate of early rebleeding oesophageal varices after band ligation in the Sohag University Hospital, Egypt, and to assess different clinical, biochemical, ultrasonographic, and endoscopic parameters that may predict the risk factors of rebleeding. Patients and methodsIn the period from December 2011 to December 2012, we performed endoscopic variceal ligation (EVL) for 146 cirrhotic patients (105 male and 41 female) with a mean age of 51.77±10.47years; the patients were divided into rebleeding and non-rebleeding groups. Complete history taking, clinical examination, laboratory investigations, abdominal ultrasound (US), and upper gastrointestinal (GI) endoscopy were performed for all patients. ResultsThe incidence of early rebleeding after EVL was 20.54%, and it was significantly associated with male gender (p=0.013), older age (p=0.009), infection with spontaneous bacterial peritonitis (SBP) (p<0.0007), reduced liver size (p=0.017), a coarser echo pattern (p=0.03), the presence of hepatic focal lesions (p<0.001), splenomegaly (p=0.02), the presence of portosystemic collaterals (p=0.006), a low haemoglobin (HB) level (p<0.0001), prothrombin concentration (p=0.017), high aspartate aminotransferase (AST) level (p=0.01), Child–Pugh B and C (p=0.02, 0.003), large oesophageal varices F3 in the two endoscopies (p=0.002; p<0.0001), varices extending to the superior third Ls (p<0.001), and the presence of massive red colour signs (RC+++) (p<0.0001). By multivariate analysis, SBP and low HB level were found to be independent predictors of rebleeding. ConclusionThe following conclusions were drawn from this study: (1) The incidence of rebleeding after EVL in our centre is about 20%. (2) Early rebleeding after EVL is affected by many clinical, laboratory, ultrasonographic, and endoscopic parameters. The most prominent of them are SBP, splenomegaly, the presence of collaterals, anaemia, more decompensated cirrhosis, and the presence of large varices with red signs. (3) SBP and low HB level were found to be independent predictors of rebleeding.

Recurrence and Mortality Among Patients Hospitalized for Acute Lower Gastrointestinal Bleeding

The long-term recurrence of lower gastrointestinal bleeding (LGIB) and associated mortality have not been studied extensively. We investigated rates of recurrence of LGIB, mortality, and associated risk factors. In a retrospective study, we analyzed data from 342 patients hospitalized for overt LGIB at the National Center for Global Health and Medicine in Japan from December 2004 through June 2013. All patients underwent colonoscopy. We assessed Charlson comorbidity index scores and the use of nonsteroidal anti-inflammatory drugs, low-dose aspirin, other antiplatelet drugs, or warfarin. Rebleeding, the total number of rebleeding episodes, and mortality were measured. The Cox proportional hazards model was used to estimate hazard ratios (HRs). Rebleeding occurred in 84 patients, at a mean follow-up time of 19 months. The cumulative percentages of patients with rebleeding at 1 and 5 years were 19% and 46%, respectively. During the follow-up period, 29 patients (39%) had secondary rebleeding and 18 patients (62%) had subsequent rebleeding. Multivariate analysis showed age 65 years and older (HR, 1.7; P= .04) and the use of nonsteroidal anti-inflammatory drugs (HR, 2.0; P < .01) and nonaspirin antiplatelet drugs (HR, 1.8; P < .05) as independent risk factors for rebleeding. Dual therapy had a higher risk than single therapy (adjusted HR, 1.8; P < .05). During the mean follow-up period of 28 months, 21 patients died (2 from bleeding). Cumulative mortality rates at 1 and 5 years were 4.2% and 13%, respectively. Mortality was associated significantly with age ≥65 years (P < .05), Charlson comorbidity index score, and warfarin use. Based on a retrospective analysis of patients with LGIB, 46% of all patients have rebleeding, and the overall mortality rate is 13% within 5 years after hospitalization. Besides age ≥65 years, use of antithrombotic drugs increases the risk of bleeding recurrence and mortality among patients with LGIB.

The influential roles of antibiotics prophylaxis in cirrhotic patients with peptic ulcer bleeding after initial endoscopic treatments.

The influential roles of antibiotic prophylaxis on cirrhotic patients with peptic ulcer bleeding are still not well documented. The purpose of this study is to clarify these influential roles and to identify the risk factors associated with rebleeding, bacterial infection and in-hospital mortality. A cross-sectional, chart review study was conducted on 210 cirrhotic patients with acute peptic ulcer hemorrhage who underwent therapeutic endoscopic procedures. Patients were divided into group A (with prophylactic intravenous ceftriaxone, n = 74) and group B (without antibiotics, n = 136). The outcomes were length of hospital days, prevention of infection, rebleeding rate and in-hospital mortality. Our results showed that more patients suffered from rebleeding and infection in group B than group A (31.6% vs. 5.4%; p<0.001 and 25% vs. 10.8%; p = 0.014 respectively). The risk factors for rebleeding were active alcoholism, unit of blood transfusion, Rockall score, model for end-stage liver disease score and antibiotic prophylaxis. The risk factors for infection were active alcoholism, Child-Pugh C, Rockall score and antibiotic prophylaxis. Rockall score was the predictive factor for in-hospital mortality. In conclusions, antibiotic prophylaxis in cirrhotic patients after endoscopic interventions for acute peptic ulcer hemorrhage reduced infections and rebleeding rate but not in-hospital mortality. Rockall score was the predictive factor of in-hospital mortality.

Su1593 The Risk of Rebleeding After Endoscopic Hemostasis Differs According to the Use of Aspirin Medication At the Time of Initial Upper Gastrointestinal Bleeding

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify the risk factors for rebleeding after a successful endoscopic hemostasis according to the use of antithrombotics.

Risk Factors for Re-bleeding of Aneurysmal Subarachnoid Hemorrhage: Systemic Review and Meta Analysis

Abstract Objective : The mortality of re-bleeding is high and patients surviving are usually in poor clinical condition and have a worse outcome than patients with single bleed. We performed an update systemic review and Meta-analysis to determine the most common risk factors for re-bleeding in aneurysmal subarachnoid hemorrhage patients. Method: We reviewed all publications on the risk factors of the re-bleeding or rerupture of already bled intracranial aneurysms. This Meta analysis included studies published from the year 2000 until 2013. Pooled mean difference was calculated for the continuous variables (Age), and pooled odds ratio (OR) was calculated for categorical factors. Heterogeneity was tested first. If it is significant (p&lt;0.05), random effect model was applied, otherwise, fixed model was used. Software - Review manager was used to find pooled effects and perform significant test for each potential risk factor. Results : We identified 174 articles. Only 7 retrospective studies had met the inclusion criteria, with 2470 patients, 283 patients had aneurysmal re-bleeding. The weighted average rate of re-bleeding is 11.3% with 95% confidence interval [CI]: 10.1-12.6. Statistically significant risk factor for re-bleeding were sex (OR 1.46; 95% CI: 1.11, 1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40, 4.53), aneurysm size (OR 3.00; 95% CI: 2.06- 4.37), clinical condition (Hunt &amp; Hess) (OR 4.94; 95% CI: 2.29, 10.68), and Fisher Grade (OR 2.29; 95% CI: 1.45, 3.61). Conclusion: Sex, high SBP, high Fisher Grade, aneurysm size larger than 10 mm, and patients with poor clinical condition (Hunt &amp; Hess) were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention should be emphasized to eliminate the risk of re-bleeding and poor outcome.

Acute variceal haemorrhage in the United Kingdom: Patient characteristics, management and outcomes in a nationwide audit

Despite advances in treatment, acute variceal haemorrhage remains life-threatening. To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. Multi-centre clinical audit conducted in 212 UK hospitals. In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.

Risk Factors for Rebleeding and Prognostic Factors for Postoperative Survival in Patients with Balloon-Occluded Retrograde Transvenous Obliteration of Acute Gastric Variceal Rupture

Balloon-occluded retrograde transvenous obliteration (B-RTO) has shown great potential in controlling acute gastric variceal hemorrhage, although rebleeding related to the procedure may occur in a small percentage of patients. The purpose of this study was to identify risk factors of perioperative rebleeding and prognostic factors of postoperative survival in B-RTO performed for acute episodes of gastric variceal hemorrhage. We retrospectively analyzed 39 consecutive patients who underwent B-RTO for gastric variceal rupture at our hospital between June 2003 and May 2011. Uni- and multi-variate analyses were performed to assess risk factors for perioperative rebleeding and prognostic factors for postoperative survival. Surgical success and complete eradication of varices were achieved in 36 cases (92.3 %) and 35 cases (89.7 %), respectively. Six patients experienced rebleeding either intraoperatively (n = 3) or within 1 h after B-RTO (n = 3). Child-Pugh class C was identified as a risk factor for rebleeding on univariate (P = 0.018) and multivariate analyses (odds ratio, 6.003; P = 0.014). With a median follow-up of 23 months (range 0-106.6 months), overall survival rates at 1, 3, and 5 years were 91.7, 74.7, and 67.2 %, respectively. Multivariate analyses revealed Child-Pugh class C as a prognostic factor for survival (relative risk, 4.014; P = 0.023). Although B-RTO is generally effective in the treatment of acute gastric variceal rupture, patients classified as Child-Pugh class C have a higher risk of perioperative rebleeding and shorter survival.

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease.

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.

Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage.

Background/AimsTo evaluate the long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (NBC; Histoacryl) for treatment of bleeding gastric varices.MethodsWe retrospectively analyzed the records of 455 patients with gastric variceal hemorrhage (GVH) who were consecutively treated with NBC from January 2004 to July 2013, with a mean follow-up period of 582 days. The patients' endoscopic findings, initial hemostasis, complications, rebleeding rates, and bleeding-related death rates were reviewed.ResultsHemostasis was achieved initially in 96.9% (441/455) of patients; rebleeding occurred in 35.2% (160/455), and the bleeding-related death rate was 6.8% (31/455) during follow-up. Complications included fever (6.8%), abdominal pain (3.7%), diarrhea (1.3%), spontaneous bacterial peritonitis (0.7%), bacteremia (0.4%), and embolism (0.2%). A red-color sign on concomitant esophageal varices (EVs) (p = 0.002) and previous history of variceal bleeding (p < 0.001) were significant risk factors for rebleeding within 1 year. The Child-Pugh score (p < 0.001), presence of hepatocellular carcinoma (p = 0.001), and failure of initial hemostasis (p < 0.001) were the risk factors most closely associated with bleeding-related death.ConclusionsThis study provides a comprehensive overview of the outcomes and prognostic factors of patients with GVH. The results may help in the selection of effective treatment strategies for patients with GVH.

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

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

PTU-035 Development and Initial Validation of Prognostic Scoring Systems for lower Gastrointestinal Bleeding

IntroductionLower gastrointestinal bleeding (LGIB) is a common and heterogeneous condition, in which there is a paucity of data concerning predictors of adverse outcomes. This study aimed to identify independent risk...

Influence of endoscopic variceal ligation on liver function and risk factors of rebleeding

To investigate the influence of endoscopic variceal ligation (EVL) on liver function and analyze the risk factors of rebleeding after EVL. A total of 137 cirrhotic patients with esophageal varices who received EVL were retrospectively analyzed, and divided into group A, B, and C according to the Child-Pugh scores of liver function. We compared the liver function 1 week preoperatively and postoperatively. The patients were further divided into a rebleeding group and a non-rebleeding group after the EVL, and risk factors about rebleeding were analyzed. There was no significant difference on ALT, AST, T-Bil, and D-Bil either preoperatively or postoperatively in group A, B, and C (P>0.05). Thirteen patients (9.49%) rebled after the EVL. The course of disease, liver function, prothrombin time, and mass ascites were the risk factors of rebleeding. EVL has no obvious effect on liver function, and the course of disease, liver function, prothrombin time and mass ascites are risk factors of rebleeding after EVL.

Frequency of rebleeding events in obscure gastrointestinal bleeding with negative capsule endoscopy

Although capsule endoscopy (CE) is widely used as a first-line diagnostic modality for obscure gastrointestinal bleeding (OGIB), the rebleeding rate after negative CE varies according to different studies. We tried to elucidate the outcomes after negative CE for OGIB and to determine the risk factors associated with rebleeding. We retrospectively reviewed data from 125 patients who had received CE for OGIB. PillCam SB capsules were used for 92 patients (73.6%) and SB2 capsules for the other 33 (26.4%). The complete visualization of the small bowel was achieved in 93 patients (74.4%). Of the 63 patients (50.4%) who showed negative CE results, 60 patients did not receive any further specific treatment for OGIB, and were analyzed for the rebleeding rate and risk factors for rebleeding. Of the 60 patients, rebleeding episodes were observed in 16 patients (26.7%), and the cumulative rebleeding rates after 6, 12, 24, and 36 months were 12.4%, 14.3%, 28.7%, and 35.9%, respectively. Substantial rebleeding events were observed with similar frequency both after negative CE without subsequent treatment (26.7%) and after positive CE without specific treatment (21.2%) (P = 0.496). Considerable rebleeding episodes were observed after negative CE result for OGIB. Further complementary diagnostic work-ups and close follow-up are needed to be considered for patients with OGIB and negative CE results.

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

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

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

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

Risk factors for rebleeding following endoscopic hemostasis in peptic ulcers

【目的】上部消化管出血に対する内視鏡的止血術は確立された手技であり，技術・機器の進歩により多くの症例で止血可能であり，成功率も向上している。しかし，再出血例，止血困難例も存在し，IVR（interventional radiology）や外科的治療が必要になる症例もみられる。当院における内視鏡的止血術の現状と止血成績について検討し，再出血の危険因子を明らかにする。【対象と方法】2008年1月〜2012年11月に当院で内視鏡的止血術を施行した出血性胃・十二指腸潰瘍141例を対象としretrospectiveに検討した。対象例を永久止血例，再出血例の2群に分け患者背景，止血方法，病変部位などについて比較を行った。また，再出血の危険因子を患者背景因子，内視鏡関連因子，術者関連因子から多変量解析で検討した。【結果】内視鏡的止血術を施行した141例の内訳は平均年齢67.2±16歳，男女比は104：37であった。再出血例は13.5％（19/141）であった。止血成功例，再出血例で比較検討した結果，基礎疾患を有する症例，輸血を施行した症例で有意差を認めた。多変量解析では基礎疾患を有する症例が独立した危険因子となる可能性が示唆された。【結論】基礎疾患を有する症例は再出血を来す可能性があり，厳重な経過観察が必要である。

Outcome in obscure gastrointestinal bleeding after capsule endoscopy

To investigate the clinical impact of capsule endoscopy (CE) after an obscure gastrointestinal bleeding (OGIB) episode, focusing on diagnostic work-up, follow-up and predictive factors of rebleeding. Patients who were referred to Hospital del Mar (Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid anti-inflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings (significant or non-significant), work-up and patient outcomes were analyzed from electronic charts. Variables were compared by χ (2) analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. There were 105 patients [45.7% women, median age of 72 years old (interquartile range 56-79)] and a median follow-up of 326 d (interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1% (55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients (69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios (HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above (HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE (HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.