Risk Of Further Bleeding Research Articles

Adherence to patient blood management strategy in patients with gastrointestinal bleeding: a prospective nationwide multicenter study.

Patient blood management (PBM) adherence in clinical practice is unclear. This real-world practice study assessed the management of patients with gastrointestinal (GI) bleeding after the implementation of the PBM strategy. This was a nationwide multicenter and prospective study involving consecutive adults with GI bleeding between March 2019 and March 2021. Patients were examined according to hemoglobin (Hb) level at admission (<7 g/dl, n = 93; 7-8 g/dl, n = 47; 8-9 g/dl, n = 61; and >9 g/dl, n = 249). Study outcomes measures were morbidity and mortality during hospitalization and at 3- and 6-month follow-up. Appropriate anemia or iron deficiency management was considered when adherence to PBM policy was higher than 75%. A total of 450 patients (57.6% men, median age: 74 years, interquartile range: 63-82) were included. Overall, 55.1% and 59.3% of patients received transfusion and iron supplementation, respectively. The rates of appropriate transfusion and iron supplementation adherence were 90.9% (range: 86.9-93.5%, P = 0.109) and 81.8% (range: 78.5-85.1%, P = 0.041), depending on Hb level, respectively. No associations were observed between adherence to the PBM strategy and length of stay (P = 0.263) or risk of further bleeding (P = 0.742). Patients who were transfused [hazard ratio (HR): 0.79, 95% confidence interval (CI): 0.27-0.85] and iron supplemented (HR: 0.91, 95% CI: 0.38-1.41), however, appropriately achieved a lower risk of death. Age (HR: 1.12, 95% CI: 1.12-1.25) and further bleeding (HR: 39.08, 95% CI: 4.01-181.24) were poor prognostic factors. No serious adverse events were reported. In this nationwide study, there is a high level of adherence and safety of PBM for the treatment of GI bleeding. Adherence to the PBM strategy improved outcomes in patients with GI bleeding.

Management of paediatric post-tonsillectomy bleeds - does everyone need observation?

The management of patients who present with a post-tonsillectomy bleed (PTB) who are not actively haemorrhaging is contentious. In our institution, those without an active bleed are admitted for a period of observation, due to the theoretical risk of further bleeding. This paper aims to review PTB admissions to ascertain the risk of rebleeding while under observation and to identify whether there is a low-risk group who can be safely discharged without observation. Review of current literature. Retrospective chart review of all patients who presented to Perth Children's Hospital between February 2018 and February 2022 with a PTB. Exclusion criteria included primary PTB, known blood dyscrasias and patients >16 years of age. A total of 826 presentations of secondary PTB (sPTB) were reviewed, with 752 admitted for a period of observation. Twenty-two (2.9%) patients rebled while under observation, with 17 managed operatively. The average age of patients who rebled was 6.2 years and they presented at an average 7.14 post-operative days. The median time to rebleed was 4.4h. Four patients with no oropharyngeal clot at presentation subsequently re-bled (0.53%) while under observation, with 2 (0.26%) managed surgically. In patients observed with an oropharyngeal clot at presentation 18 (3.1%) rebled, with 15 (2.6%) managed operatively. Patients presenting with a sPTB have a low risk of rebleeding while under observation. Patients with a normal oropharyngeal examination at presentation have a very low risk of rebleed and should be considered for early discharge if they meet other low risk criteria. Patients who present with an oropharyngeal clot can be safely observed with a low risk of further bleeding. Patients who rebleed while under observation should have a trial of conservative management if clinically appropriate.

Surgical management of pulmonary aspergilloma

: Pulmonary aspergillomas occur due to the aspergillus fungus colonising pre-existing cavities within the lungs of patients with underlying lung pathology or in those who are immunosuppressed. Their clinical presentation can be variable and they often present to the surgical clinic after patients develop haemoptysis. This haemoptysis can vary from mild bleeds to catastrophic life-threatening haemorrhage. Surgery for patients with aspergillomas historically carried a high morbidity and mortality impact and so the role of surgery was usually saved for patients presenting with severe haemoptysis. In recent years further research has demonstrated a reduction in the morbidity and mortality impact of surgery and therefore the question has been raised whether surgical intervention should be offered at an earlier stage. Surgery for pulmonary aspergilloma is technically challenging and does still carry a marked morbidity and mortality risk. Although these risks have reduced in recent years, surgery should still be reserved for symptomatic patients with a significant risk of further bleeding. A multi-disciplinary framework is crucial to offer best risk; benefit assessment and discussion for this high-risk patient group. This article will describe the natural history and presentations of aspergillomas, the indications and types of surgery as well as a multi-disciplinary approach to patient assessment.

The influences of timing of urgent endoscopy in patients with acute variceal bleeding: a cohort study

Therehas always beena debateontheoptimal timingofendoscopy in patients with acute variceal bleeding(AVB). This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB. Patients with AVB who underwent endoscopy within 24h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. WeusedCox proportional hazards model to analyze the predictors of 6-week mortality in all patientsaswellasin those who were at high risk of further bleeding or death. A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6h), and 142 patients (45.51%) underwent early endoscopy (6-24h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06-0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902). Endoscopy performed within 6h of admission, rather than within 6 to 24h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death.

Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy.

For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes.The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.

Thrombosis and Bleeding as Presentation of COVID-19 Infection with Polycythemia Vera. A Case Report.

Coronavirus disease (COVID-19) has a wide spectrum of clinical manifestations. In this case report, we describe our first case of COVID-19 pneumonia that was complicated by cerebral venous thrombosis and bleeding in a patient with polycythemia vera. Madam A, a 72-year-old lady with polycythemia vera, ischemic stroke, hemorrhoids, diabetes mellitus, hypertension, and dyslipidemia was admitted to the hospital for COVID-19 pneumonia. She was treated with hydroxychloroquine and lopinavir/ritonavir as per hospital protocol. She continued taking hydroxyurea and aspirin for her treatment of polycythemia vera. Subsequently, she developed rectal bleeding when her platelet count was 1247 × 103/μl, even though she was not on an anticoagulant. Her aspirin was withheld. One week later, she was readmitted to the hospital for cerebral venous thrombosis and her D-dimer was 2.02 μg/ml. She was commenced on a therapeutic dose of low molecular weight heparin. Following that, her D-dimer level showed a decreasing trend and normalized upon her discharge. Patients with polycythemia vera are prone to develop thrombotic and bleeding complications. Management of this group of patients has become more complex with COVID-19 infection. It is crucial for us to decide when to start an anticoagulant especially when there is a history of recent bleeding. We need to balance the risks of further bleeding versus potentially fatal thrombotic events. Studies have shown that D-dimer can be used as a clinical marker to predict thrombotic events in COVID-19 infection. Patients with COVID-19 infection and polycythemia vera will benefit from both pharmacological thromboprophylaxis and close monitoring for bleeding.

S1529 Occult Portobiliary Fistula Following Percutaneous Liver Biopsy

INTRODUCTION: Percutaneous liver biopsies are commonly performed procedures in the diagnostic workup or staging of liver diseases, and bleeding is the most important complication. Hemobilia is defined as bleeding into the biliary tree, and is a rare complication of liver biopsy that classically presents with a triad of GI bleeding, abdominal pain, and jaundice. CASE DESCRIPTION/METHODS: A 44-year-old male underwent an uneventful liver biopsy for workup of hepatic steatosis. The next day he presented to the ER with RUQ abdominal pain and jaundice. Vital signs were normal and physical examination revealed scleral icterus and epigastric tenderness. Liver function tests showed AST and ALT of 2248 U/L and 2915 U/L, respectively, alkaline phosphatase of 200 U/L, and total bilirubin of 23.3 mg/dL with direct bilirubin of 13.9 mg/dL. CT scan revealed small hemoperitoneum and diffuse hepatic steatosis. Ultrasound with doppler showed normal biliary and intrahepatic ducts and patent portal and hepatic veins with normal blood flow. On the fourth hospital day, MRCP revealed moderate right intrahepatic biliary ductal dilatation with associated hemobilia to the level of the biliary confluence (Figure 1). MRI with contrast revealed completely thrombosed right portal vein and branches, and persistent right intrahepatic biliary ductal dilatation (Figure 2). Oral anticoagulation was considered; however, the gastroenterology team felt the liver biopsy caused an iatrogenic portobiliary fistula, leading to the formation of the portal vein thrombus which may have helped seal the fistula. Therefore, the decision was made to hold anticoagulation and discharge the patient. Liver function tests one month later revealed AST and ALT of 20 U/L and 70 U/L respectively. Repeat MRI showed a reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus with recanalization and mild cavernous transformation (Figure 3). DISCUSSION: Given the biliary dilation on MRCP, we suspect that a blood clot at the biliary confluence caused an obstruction leading to acute severe rise in AST, ALT and direct hyperbilirubinemia. Due to the risk of further bleeding and possible tamponade effect of clot, anticoagulating the patient may have worsened the situation. Portobiliary fistulas leading to hemobilia are a rare complication of percutaneous liver biopsy. While GI bleeding, jaundice, or abdominal pain post-biopsy should prompt a diagnostic workup, it should also be kept in mind that there could be uncommon presentations of hemobilia.Figure 1.: MRCP showing moderate right intrahepatic biliary ductal dilatation with associated hemobilia.Figure 2.: Contrast enhanced MRI showing thrombosed right portal vein and branches, and right intrahepatic biliary ductal dilatation.Figure 3.: Follow-up MRI showing reduction of right intrahepatic biliary dilation, and chronic right portal vein thrombus.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Inherited Bleeding Disorders in Pediatric Patients; experience of the national referral center in Iraq.

Inherited bleeding disorders can lead to lifelong bleeding; they are mainly caused by quantitative or qualitative defect of coagulation factors, von Willebrand factor (VWF) or platelets. No published data are available about the different types of inherited bleeding disorders in Iraq. To describe types, severity and presentation of inherited bleeding disorders in pediatric patients in the major referral center in Iraq. This is a cohort prospective descriptive study conducted at the National Center of Hematology, a referral center for bleeding disorders in Baghdad-Iraq, from January 2015 to December 2019. One hundred ninety-one patients, aged 1day to 14years, with suspected inherited bleeding disorder are included in this study. Each patient was interviewed, accompanied by a chaperone, mostly parent(s), with revision of personal and familial bleeding history, conducting a brief medical examination, and withdrawing blood for complete blood count, peripheral blood film, bleeding time, PT and APTT. Further investigations including mixing studies, lupus anticoagulant, clotting factor activity, VWF:antigen (VWF:Ag), VWF: Ristocetin cofactor (VWF:RiCof) and platelet function tests using light transmission aggregometry were performed only if indicated. The mean ± 1SD of age of patients is 5.3 ± 3years, with a male:female ratio of 1.3:1. Family history of a similar bleeding disorder is recorded in 44.9% patients (P < 0.05). Consanguineous marriage was observed in 70.8% of the families (P < 0.001). The most prevalent inherited bleeding disorder is von Willebrand disease (VWD) (43.9%), of which type 3 is the most common (86.9%). Thrombasthenia is the second most prevalent (39.8%) inherited bleeding disorder; of these, the majority have Glanzmann's thrombasthenia (82.9%). Hemophilia A is found in 9.4% of patients. Type 3 VWD, Glanzmann's thrombasthenia and hemophilia A are the most common inherited bleeding disorders in the central part of Iraq, collectively they constitute >86% of patients. Consanguineous marriage should be discouraged in our society to decrease hereditary bleeding disorders. Also, there is a need to increase awareness and knowledge of bleeding disorders to improve early identification, mitigate the risk of further bleeding and prevent complications.

P0545DPP-4 INHIBITOR ATTENUATED RENAL VASOCONSTRICTION FOLLOWING ISCHEMIA-REPERFUSION INJURY IN CIRRHOTIC RATS

Abstract Background and Aims Cirrhotic patients may develop gastroesophageal varices to cope with portal hypertension. Annual risk of variceal bleeding among small and large varices is 5% and 15%, respectively. Bleeding from varices is a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other serious complications remain high, such as hypotension and ischemia-reperfusion injury. Ischemia-reperfusion injury is a leading cause of acute kidney injury. In patients with advanced liver cirrhosis, variceal bleeding associated hypotension and ischemia-reperfusion injury may activated endogenous vasoconstrictors, leading to severe renal vasoconstriction and subsequent renal failure (so called hepatorenal syndrome). There was not effective treatment yet. Dipeptidyl peptidase-4 (DPP-4) inhibitors, a new class of oral hypoglycemic agents, have shown potential pleiotropic effects, such as anti-inflammatory and anti-oxidant properties. Previous studies reported that inhibition of DPP-4 could attenuate the development of ischemia-reperfusion injury in kidney. Cumulated evidences indicates that DPP-4 inhibitors could attenuate the endothelin-1 induced contraction and increase endothelial-dependent vasodilation related to activation of endothelial nitric oxide synthase and increased production of nitric oxide. In addition, DPP-4 inhibitors may suppress inflammation and fibrosis in the kidneys independently of glycemic control. The aim of this study is to delineate the effect of DPP-4 inhibitors in renal vascular reactivity of cirrhotic rats following ischemia-reperfusion injury. Method Male Sprague-Dawley rats weighing 240-270 g were used for experiments. Secondary biliary cirrhosis were created by common bile duct ligation (CBDL). Rats receiving sham surgery (SHAM) were used as the control group. Linagliptin (3 mg/kg/day) or distilled water (DW) was administered via oral gavage since the 1st day throughout the 28th day after surgery. On the 29th day, all rats were randomized to control group or ischemia-reperfusion injury. Bilateral renal pedicles of rats in the ischemia-reperfusion injury group were clamped for 45 minutes with microvascular clamps. Thereafter, the clamps were removed and reperfusion was allowed by visual control. After 60 minutes of reperfusion period, kidneys were perfused in situ via right renal artery for continuous monitoring of renal perfusion pressure using a non-recirculating system. Results There was no significant difference in mean arterial pressure, heart rate, and portal pressure between DW and DPP-4 inhibitor treated groups in both SHAM and CBDL rats. Ischemia-reperfusion injury enhanced renal vascular reactivity to endothelin-1 in both SHAM (p = 0.027) and CBDL (p = 0.016) rats, implying renal vasoconstriction. Compared with corresponding DW-treated rats, DPP-4 inhibitor treatment abrogated renal hyper-reactivity following ischemia-reperfusion injury in BDL rats (p = 0.038), but not in SHAM rats (p = 0.17). Conclusion We concluded that DPP-4 inhibitors may attenuate the development of renal vasoconstriction following ischemia-reperfusion injury in cirrhotic rats. The potentially mechanisms remained to be elucidated.

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

BackgroundIt is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined.MethodsTo evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow–Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.ResultsA total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], −2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, −1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.ConclusionsIn patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.)

A Rare Cause of Upper GI Bleed Caused by Duodenal Lipoma

Lipomas are slow growing masses consisting of mature fat tissue that usually appear in the subcutaneous tissue of the trunk and extremities. Lipomas of the gastrointestinal tract are uncommon but occasionally when found, usually appear in the colon with duodenal lipomas being rare. This case presents a patient with a large duodenal lipoma with ulceration causing brisk upper GI bleeding. A 76 year-old female with past medical history of hypertension presented with dyspnea on exertion since four days. It was associated with chest discomfort, dizziness and relieved on rest. She also reported intermittent black stools of unknown duration but no bright red blood or vomiting. There was no history of NSAID or steroid use. Her exam was significant for hypotension and pallor. She did not exhibit any abdominal tenderness. Rectal exam revealed heme positive brown stool. Her labs revealed critical hemoglobin and hematocrit of 3.7 gm/dL and 13.5%. CT of the abdomen showed a giant 10.7x 7.4 x 7.8 cm intraluminal lipoma in the second part of the duodenum with its stalk noted to be in the upper part of the duodenum. There were focal irregularities noted in the anterior portion suggesting ulceration but no contrast extravasation to suggest active bleeding. The patient was admitted to the ICU for aggressive resuscitation with blood products and continued supportive care. EGD was done, which revealed a large duodenal bulb mass with multiple areas of superficial ulceration that may have served as a bleeding source. There were no stigmata of active bleeding. The biopsy report after discharge revealed that the mass had evidence of inflammatory changes and negative for malignancy. Due to its size and risk of further bleeding, surgical removal was recommended but the patient refused. The presence of duodenal lipoma is underreported in the literature, with peak incidence around the 5th and 7th decade of life. Approximately 64% of GI tract lipomas are found in the colon with only 4% seen in the duodenum. They are mostly asymptomatic and usually present as upper GI bleeding. Other clinical manifestations include ulceration, intussusceptions, or bowel obstruction. CT scan, EUS and MRI can be used for diagnosis with confirmation obtained with biopsy. The management depends on the size and symptoms. Larger GI lipomas requiring surgical resection and small lipomas can safely be treated with snare polypectomy via endoscopy. If resected the diagnosis should be confirmed histologically.2491_A Figure 1. A transverse view of CT Abdomen showing: A giant intraluminal lipoma in the second part of the duodenum, measuring 10.7 cm x 7.4 cm x 7.8 cm (white arrow). There is irregularity of the anterior margin near the stalk of the lipoma, which could suggest underlying ulceration (red arrow).2491_B Figure 2. A coronal view of CT Abdomen showing:: A giant intraluminal lipoma in the second part of the duodenum, measuring 10.7 cm x 7.4 cm x 7.8 cm (white arrow).2491_C Figure 3. Endoscopic image of the large duodenal bulb mass with multiple areas of ulceration.

The association between red blood cell transfusion and outcomes in patients with upper gastrointestinal bleeding.

BackgroundThe benefits of transfusion for acute upper gastrointestinal bleeding (UGIB) have not been well established; however, previous studies suggest that transfusion is associated with adverse outcomes. We performed an observational study using a 10-year database to analyze the association between red blood cell (RBC) transfusion and outcomes in patients with UGIB in the emergency department (ED).Method and findingsAll adult patients with UGIB were identified through diagnostic codes. Hospital mortality was the primary outcome; further bleeding was the secondary outcome. Logistic regression, propensity analyses, and conditional logistic regression were performed to determine factors associated with outcomes. Of 59,188 enrolled patients, 31.6% (n = 18,705) received RBC transfusions within 24 h following presentation to the ED. Hospital mortality was noted in 3.9 and 10.6% of the patients in the non-RBC transfusion and RBC transfusion groups, respectively (P < 0.001). RBC transfusion was associated with increased mortality risk (unadjusted odds ratio (OR) 2.95, 95% confidence interval (CI) 2.75–3.16; P < 0.001) among all patients and in the propensity-matched cohort (unadjusted OR 1.55, 95% CI 1.39–1.72; P < 0.001). Further bleeding was noted in 5.6 and 33.8% of the patients in the non-RBC transfusion and RBC transfusion groups, respectively (P < 0.001). RBC transfusion was associated with increased risk of further bleeding (unadjusted OR 8.60, 95% CI 8.16–9.06; P < 0.001) among all patients and in the propensity-matched cohort (unadjusted OR 2.58, 95% CI 2.37–2.79; P < 0.001).ConclusionRBC transfusion was significantly associated with increased rates of hospital mortality and further bleeding in patients with UGIB. Although our findings have strengths, these results are not generalizable to all patients presenting with UGIB, especially patients presenting with exsanguinating bleeding. Additional prospective trials to guide optimal transfusion strategies in UGIB patients are needed.

Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies.

Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).

Recent advances in the management of variceal bleeding.

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized–controlled trials or meta-analyses that support current treatment algorithms.

Early transjugular intrahepatic portosystemic shunt in US patients hospitalized with acute esophageal variceal bleeding.

Early transjugular intrahepatic portosystemic shunt (TIPS) used as preventive therapy prior to recurrent bleeding has been recommended in patients presenting with acute esophageal variceal bleeding (EVB) who are at high risk of further bleeding and death. We investigated the impact of early TIPS on outcomes of US patients hospitalized with EVB from 2000 to 2010. The Nationwide Inpatient Sample database was queried to identify patients with EVB and decompensated cirrhosis (because early TIPS is recommended only in high-risk patients). The primary outcome was in-hospital death, and secondary outcomes included rebleeding and hepatic encephalopathy. Early preventive TIPS was defined by placement within 3 days of hospitalization for acute EVB after one session of endoscopic therapy. Rescue TIPS was defined as TIPS after two interventions for EVB. The study included 142 539 patients. From 2000 to 2010, the age-adjusted in-hospital mortality rate decreased 37.2% from 656 per 100 000 to 412 per 100 000 (P <0.01), while early and rescue TIPS increased (0.22% to 0.70%; P < 0.01 and 1.1% to 6.1%; P < 0.01). On multivariate analysis, as compared with no TIPS, early TIPS was associated with decreased inpatient mortality (risk ratio [RR] = 0.87; 95% confidence interval [CI], 0.84-0.90) and rebleeding (RR = 0.56; 95% CI, 0.45-0.71) without an increase in hepatic encephalopathy (RR = 1.01; 95% CI, 0.93-1.11). Early preventive TIPS in patients with EVB and decompensated cirrhosis was associated with significant in-hospital reductions in rebleeding and mortality without a significant increase in encephalopathy in "real-world" US clinical practice.

Magnetic resonance imaging in patients with atrial fibrillation before left atrial appendage closure after brain hemorrhage

Background: Brain MRI may be helpful for selecting patients at higher risk of further bleeding after a first hemorrhagic stroke in patients with atrial fibrillation treated by oral anticoagulants. MRI may detect imaging markers consistent with an increased risk of further bleeding that could improve patient selection for left atrial appendage closure (LAAC). Method: We studied clinical and imaging data of patients with atrial fibrillation treated by oral anticoagulants who experienced hemorrhagic stroke. MRI was performed for the detection of small vessels disease abnormalities (cerebral amyloid angiopathy (AA) or severe hypertensive microangiopathy) suggesting a higher hemorrhagic risk thus supporting the choice of LAAC closure instead of anticoagulants to prevent thromboembolic events. Results: Between December 2013 and February 2016, 37 patients were included. Among them 25 patients experienced brain hemorrhage and underwent a cerebral MRI before LAAC. 16% (4/25) had severe white matter damage, 24% (6/25) exhibit MRI features consistent with hypertensive microangiopathy/or multiple cortical microbleeds (CMBs) and cortical superficial siderosis (CSS) consistent with AA. 16% (4/25) with mixed anomalies and 11 (44%) had undetermined small vessel disease. Conclusion: Brain MRI after a first hemorrhagic stroke may provide helpful information on the risk of bleeding recurrence before LAAC.

Transient thromboembolic event in a child with severe hemophilia a due to venous obstruction

Venous thrombosis is a very rare occurrence in patients with hemophilia A. We present a one year old child with severe hemophilia A, who developed deep vein thrombosis in antecubital fossa following venous obstruction due to bleeding around the vein. We didn’t start anticoagulant therapy to our patient because of the risk of further bleeding into subdural hemorrhage he had already developed. We could manage the thrombosis and save the limb by relieving the obstruction with replacement of factor VIII.

Overview of Venous Thrombosis in Inflammatory Bowel Disease

Thrombosis in inflammatory bowel disease (IBD) is an increasingly noted extraintestinal manifestation with high morbidity and mortality. While controlling the activity of the disease with the appropriate therapy, thromboembolism prophylaxis should be applied to all patients. All common risk factors for thromboembolism are also valid for patients with IBD; however, it is clear that uncontrolled disease and hospitalization are major disease-specific risk factors for venous thromboembolism in patients with IBD. Pharmacological thromboprophylaxis with currently available anticoagulants does not increase the risk of further bleeding in patients with IBD with mild-to-moderate bleeding. In severe bleeding or with increased risk of further bleeding due to other comorbid conditions, thromboprophylaxy with mechanical methods should be the treatment option. Whether thrombosis is the cause or the result of intestinal inflammation remains to be elucidated, and other issues in the etiology, such as the role of intestinal flora in thrombosis pathogenesis, will be the subject of future studies.

Manejo anestésico para craneotomía en paciente gestante con rotura de malformación arteriovenosa cerebral: Reporte de caso

Intracranial haemorrhage (ICH) is the third leading non obstetric indirect cause of maternal death. We describe the anaesthetic management of a 32-year-old woman at 22weeks gestation with intracranial haemorrhage due to a ruptured arteriovenous malformation (AVM). Managing these patients requires a complex approach with a highly individualised plan involving neurosurgeons, neuroradiologists, anaesthetists, obstetricians and neonatologists to assess the risk and benefit of all the different therapeutic alternatives. Given the high risk of further bleeding during pregnancy and the location of the AVM, the best therapeutic option in this case was considered to be a craniotomy and complete removal of the lesion.