Risk Of Further Bleeding Research Articles

Anaesthetic management for craniotomy in a pregnant patient with rupture of a cerebral arterio-venous malformation: Case report

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 22 weeks 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.

Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers

Endoscopic therapy reduces the rebleeding rate and the need for surgery in patients with bleeding peptic ulcers. To determine whether a second procedure improves haemostatic efficacy or patient outcomes or both after epinephrine injection in adults with high-risk bleeding ulcers. For our update in 2014, we searched the following versions of these databases, limited from June 2009 to May 2014: Ovid MEDLINE(R) 1946 to May Week 2 2014; Ovid MEDLINE(R) Daily Update May 22, 2014; Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations May 22, 2014 (Appendix 1); Evidence-Based Medicine (EBM) Reviews-the Cochrane Central Register of Controlled Trials (CENTRAL) April 2014 (Appendix 2); and EMBASE 1980 to Week 20 2014 (Appendix 3). We included randomised controlled trials (RCTs) comparing epinephrine alone versus epinephrine plus a second method. Populations consisted of patients with high-risk bleeding peptic ulcers, that is, patients with haemorrhage from peptic ulcer disease (gastric or duodenal) with major stigmata of bleeding as defined by Forrest classification Ia (spurting haemorrhage), Ib (oozing haemorrhage), IIa (non-bleeding visible vessel) and IIb (adherent clot) (Forrest Ia-Ib-IIa-IIb). We used standard methodological procedures as expected by The Cochrane Collaboration. Meta-analysis was undertaken using a random-effects model; risk ratios (RRs) with 95% confidence intervals (CIs) are presented for dichotomous data. Nineteen studies of 2033 initially randomly assigned participants were included, of which 11 used a second injected agent, five used a mechanical method (haemoclips) and three employed thermal methods.The risk of further bleeding after initial haemostasis was lower in the combination therapy groups than in the epinephrine alone group, regardless of which second procedure was applied (RR 0.53, 95% CI 0.35 to 0.81). Adding any second procedure significantly reduced the overall bleeding rate (persistent and recurrent bleeding) (RR 0.57, 95% CI 0.43 to 0.76) and the need for emergency surgery (RR 0.68, 95% CI 0.50 to 0.93). Mortality rates were not significantly different when either method was applied.Rebleeding in the 10 studies that scheduled a reendoscopy showed no difference between epinephrine and combined therapy; without second-look endoscopy, a statistically significant difference was observed between epinephrine and epinephrine and any second endoscopic method, with fewer participants rebleeding in the combined therapy group (nine studies) (RR 0.32, 95% CI 0.21 to 0.48).For ulcers of the Forrest Ia or Ib type (oozing or spurting), the addition of a second therapy significantly reduced the rebleeding rate (RR 0.66, 95% CI 0.49 to 0.88); this difference was not seen for type IIa (visible vessel) or type IIb (adherent clot) ulcers. Few procedure-related adverse effects were reported, and this finding was not statistically significantly different between groups. Few adverse events occurred, and no statistically significant difference was noted between groups.The addition of a second injected method reduced recurrent and persistent rebleeding rates and surgery rates in the combination therapy group, but these findings were not statistically significantly different. Significantly fewer participants died in the combined therapy group (RR 0.50, 95% CI 0.25 to 1.00).Epinephrine and a second mechanical method decreased recurrent and persistent bleeding (RR 0.31, 95% CI 0.18 to 0.54) and the need for emergency surgery (RR 0.20, 95% CI 0.06 to 0.62) but did not affect mortality rates.Epinephrine plus thermal methods decreased the rebleeding rate (RR 0.49, 95% CI 0.30 to 0.78) and the surgery rate (RR 0.20, 95% CI 0.06 to 0.62) but did not affect the mortality rate.Our risk of bias estimates show that risk of bias was low, as, although the type of study did not allow a double-blind trial, rebleeding, surgery and mortality were not dependent on subjective observation. Although some studies had limitations in their design or implementation, most were clear about important quality criteria, including randomisation and allocation concealment, sequence generation and blinding. Additional endoscopic treatment after epinephrine injection reduces further bleeding and the need for surgery in patients with high-risk bleeding peptic ulcer. The main adverse events include risk of perforation and gastric wall necrosis, the rates of which were low in our included studies and favoured neither epinephrine therapy nor combination therapy. The main conclusion is that combined therapy seems to work better than epinephrine alone. However, we cannot conclude that a particular form of treatment is equal or superior to another.

Outcomes of peptic ulcer bleeding following treatment with proton pump inhibitors in routine clinical practice: 935 patients with high- or low-risk stigmata

Objective. To assess rates of further bleeding, surgery and mortality in patients hospitalized owing to peptic ulcer bleeding. Materials and methods. Consecutive patients hospitalized for peptic ulcer bleeding and treated with a proton pump inhibitor (PPI) (esomeprazole or pantoprazole) were identified retrospectively in 12 centers in Spain. Patients were included if they had high-risk stigmata (Forrest class Ia–IIb, underwent therapeutic endoscopy and received intravenous PPI ≥120 mg/day for ≥24 h) or low-risk stigmata (Forrest class IIc–III, underwent no therapeutic endoscopy and received intravenous or oral PPI [any dose]). Results. Of 935 identified patients, 58.3% had high-risk stigmata and 41.7% had low-risk stigmata. After endoscopy, 88.3% of high-risk patients and 22.1% of low-risk patients received intravenous PPI therapy at doses of at least 160 mg/day. Further bleeding within 72 h occurred in 9.4% and 2.1% of high- and low-risk patients, respectively (p < 0.001). Surgery to stop bleeding was required within 30 days in 3.5% and 0.8% of high- and low-risk patients, respectively (p = 0.007). Mortality at 30 days was similar in both groups (3.3% in high-risk and 2.3% in low-risk patients). Conclusion. Among patients hospitalized owing to peptic ulcer bleeding and treated with PPIs, patients with high-risk stigmata have a higher risk of further bleeding and surgery, but not of death, than those with low-risk stigmata.

Superficial Vein Thrombophlebitis with a Large Haematoma in a Varicose Vein: An Unusual Presentation

Superficial vein thrombophlebitis is a common association with varicose vein. However it may rarely present with venous haemorrhage due to rupture of varicose vein leading to life threatening complication. A 56 years old male patient presented in our hospital with pain and swelling Right lower limb and a large haematoma near right Knee. USG suggested superficial thrombophlebitis of great saphenous vein with huge haematoma. Risk of further bleeding prompted the decision to surgically remove the haematoma and stripping of great saphenous vein.This is a rare presentation associated with varicose veins.

Update on the transfusion in gastrointestinal bleeding (TRIGGER) trial: statistical analysis plan for a cluster-randomised feasibility trial

BackgroundPrevious research has suggested an association between more liberal red blood cell (RBC) transfusion and greater risk of further bleeding and mortality following acute upper gastrointestinal bleeding (AUGIB).Methods and designThe Transfusion in Gastrointestinal Bleeding (TRIGGER) trial is a pragmatic cluster-randomised feasibility trial which aims to evaluate the feasibility of implementing a restrictive vs. liberal RBC transfusion policy for adult patients admitted to hospital with AUGIB in the UK. This trial will help to inform the design and methodology of a phase III trial. The protocol for TRIGGER has been published in Transfusion Medicine Reviews. Recruitment began in September 2012 and was completed in March 2013. This update presents the statistical analysis plan, detailing how analysis of the TRIGGER trial will be performed. It is hoped that prospective publication of the full statistical analysis plan will increase transparency and give readers a clear overview of how TRIGGER will be analysed.Trial registrationISRCTN85757829

Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-term Risks of Rebleeding and Death

Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes. We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years. After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival. Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.

Treating Mild Stroke Could Save Patients From Disabilities and Millions of Dollars

LOS ANGELES – The use of clot-busting drugs in patients with mild stroke could save thousands of them from long-term stroke-related disability and reduce annual health care costs about $200 million. The decision to administer tissue plasminogen activator (tPA) to patients with mild stroke is a difficult one, balancing the possible benefits with the risk of further bleeding, Dr. Pooja Khatri said during a press briefing at the International Stroke Conference. But her epidemiologic study of 150 mild strokes – only four of which were treated with tPA – suggests that administering the drug could prevent the disabilities that affect up to one-third of these patients. Her retrospective study drew its data from the Greater Cincinnati/Northern Kentucky Stroke Study. The database included 441 patients in that region who were treated for ischemic stroke during 2005. Of those, 56% (247) had strokes that were considered mild, with a baseline modified Rankin Scale score of 2-6. And of those patients, 62% (150) were considered eligible for tPA treatment; however, only 1% (4) received the drug. Dr. Khatri, director of acute stroke at the University of Cincinnati Academic Health Center, did not follow the patients to compare clinical outcomes over time. However, she said, based on two extant studies, about 30% of mild stroke patients do experience deficits that affect their lives. “They might not able to drive, go back to work, or take care of themselves,”. she said in an interview. She extrapolated her findings to the entire U.S. population in 2010, estimating that mild strokes would have occurred in 27,203 patients without baseline disability. If all of the these patients had received an effective treatment, such as the current clot-busting drugs or a milder form that could be developed, up to 13% (3,761) could be saved from disabling stroke-related disability. “We could see a savings of $200 million across the country,” she said. an eher data don't directly address the day-to-day decisions clinicians have to make when faced with a mild stroke patient. A tiny fraction of mild stroke patients receive tPA treatment, she said, because generally the potential gains are regarded as small, compared with the risk of aggravated brain hemorrhage. “That [untreated] patient may end up being paralyzed on one side or having cognitive problems that we didn't recognize in the emergency department,” Dr. Khatri said. “On the other hand, we may treat and that patient can bleed and perhaps even die.” The dilemma can be answered only by a large, randomized trial, she said – something she and her colleagues at the University of Cincinnati are trying to get started. “Our group is planning such a study, to randomize those with mild stroke to tPA or placebo and then follow them, characterizing their hemorrhage rates as well as their disability outcomes.” “This study is a wake-up call to us, from the standpoints of both cost and the patient's personal day-to-day life,” said Steven M. Greenberg, MD, PhD, the director of hemorrhagic stroke research at Massachusetts General Hospital, Boston. “From it, we can almost argue that every stroke is significant. Even strokes that people are unaware of are probably significant in terms of future disability, so we need to take all mild strokes very seriously when deciding treatment.” Neither Dr. Khatri nor her coauthors disclosed any conflict. Michele G. Sullivan is with the Mid-Atlantic bureau of Elsevier Global Medical News.

Anticoagulation Therapy Following Embolic or Hemorrhagic Stroke in the Patient with a Mechanical Heart Valve

Background: An estimated 95,000 heart valve replacements are performed annually in the United States. Prosthetic valves may be either mechanical or bioprosthetic in composition. Mechanical valves offer added durability but commit the patient to taking lifelong anticoagulant therapy. Maintaining therapeutic levels of anticoagulation may be challenging, and inadequate anticoagulation can lead to thromboembolic or hemorrhagic complications. When a patient with a mechanical valve suffers a stroke, management of anticoagulation becomes more controversial and complicated. This article reviews the available evidence and guidelines for management of systemic anticoagulation following stroke in patients with mechanical heart valves. Methods: A review of the PubMed database for pertinent articles, using the keywords “mechanical heart valve”, “anticoagulation”, “cerebrovascular accident”, and “stroke”. The clinical guidelines offered by the American College of Cardiology, American Heart Association, and American Stroke Association were also reviewed. Results: There are no definitive guidelines for the management of patients with mechanical heart valves who suffer a stroke. Most of the data is from small case series and retrospective reviews. Conclusion: Based on the available data, anticoagulation should be resumed rapidly following thromboembolic stroke in patients with a mechanical heart valve, once the risk of hemorrhagic transformation has declined. In the setting of a hemorrhagic stroke, it also appears safe to resume anticoagulation relatively rapidly (after approximately one week), although the risks of further bleeding must be considered. In either case, holding anticoagulation after a stroke for a few days does not expose the patient to significantly increased risk of acute thrombosis.

Management of intracranial bleeding in anticoagulated patients

Intracranial haemorrhage is a life-threatening complication of anticoagulation. When the anticoagulation is for a mechanical heart valve the risks of further bleeding on warfarin need to be balanced against the risks of thromboembolism from an unprotected valve.

Detachable coil embolisation of ruptured intracranial aneurysms: A single center study, a decade experience

Objective The introduction of detachable coils revolutionised the management of patients with intracranial aneurysms and is now considered a first-line treatment in our institution. The purpose of this study was to review 10 years of experience with this method. Methods A retrospective review of prospectively collected data on 711 patients undergoing endovascular treatment of ruptured intracranial aneurysm between 1996 and 2005 with regard to technical feasibility, procedural complications, rebleeding, anatomical outcome, need for retreatment and overall clinical outcome. Results Endovascular treatment failed in 25 aneurysms from a total of 717 (4%). Aneurysm rupture complicated 37 procedures (4.7%) leaving 10 patients permanently disabled or dead (1.3%). Thromboembolic events complicated 35 procedures (4.5%) leaving 8 patients permanently disabled or dead (1%). One other patient died because of fatal parent vessel rupture. Further 6 procedures were complicated by arterial dissection and 18 by coil loop protrusion, however all of these patients achieved independent recovery. Overall morbidity–mortality was 2.9%. Further subarachnoid heamorrhage occurred in 16 patients (2.3%), 12 of which died. Altogether, 121 aneurysms from 511 (24%) were recanalized on follow up angiography, 52 required retreatment (7.1%). At 6 months follow up, 580 patients (82%) were independent, while 130 patients (18%) were disabled or dead. Conclusion Detachable coil embolisation of intracranial aneurysms is a very feasible treatment method associated with a small risk of permanent morbidity–mortality. Risk of further bleeding is small, but related with devastating outcome. Approximately 25% of aneurysms will recanalize and 7% will require retreatment. Despite these shortcomings, vast majority of patients will achieve independent recovery.

Surgical treatment of symptomatic cavernous malformations of the brainstem

Cavernous malformations (CM) at the level of the brainstem, continue to present a challenge in therapeutic terms and are an important source of controversy. Here we present our experience and the results obtained by adopting surgical treatment. The results of a consecutive series of 17 patients were studied. The surgical intervention was designed after: 1. A neurological examination. 2. MRI and cerebral angiography. 3. Correlation with anatomical brainstem maps. The surgical intervention was approached from the most damaged zone or through a zone which was functionally least important. Complete extirpation was achieved in 15 patients without mortality. In a few patients the surgical intervention temporarily aggravated the prior lesion of the cranial nerves (2/17) or damage new sensory tracts (2/17). The functional post-operative recovery was good, in terms of consciousness (4/5), cranial nerves (11/17), the pyramidal tract (3/5) and the cerebellum (2/4). Of the patients that were operated, 14 of 17 returned to their professional activities. The results of surgery can surpass the morbidity-mortality of the natural history or treatment with radiosurgery. There is a clear consensus in recommending surgical intervention for CMs that are superficially located, in young patients and in those with a risk of further bleeding. It is probably best that the surgery is performed during the subacute period, when the MRI offers a clear image confirming the presence of the CM.

Differenzialdiagnose von Läsionen der weißen Hirnsubstanz in der Magnetresonanztomographie

White matter signal changes in magnetic resonance imaging (MRI) are frequent and the correct clinical assessment is very important for the further clinical management of the patient. The first problem in the sequence of dealing with these patients is to determine, if a signal change is truly abnormal or a sign of normal aging. The abundance of unspecific signal changes in the brains of normal persons has lead to the creation of the term unknown bright objects (UBO) for these findings. If a white matter lesion is deemed truly abnormal, it should be categorised into one of the major categories such as microvascular, demyelinating, inflammatory, neoplastic or metabolic. Thereafter, a further classification can be attempted. The mainstay of the MRI diagnostics of white matter lesions are dark fluid T 2-weighted sequences such as fluid attenuated inversion recovery (FLAIR). In contrast to conventional T2, these images maintain a high sensitivity for white matter damage in the vicinity of the CSF spaces. T 1-weighted images prior to contrast administration have been shown to demonstrate the clinical significant lesion load whereas the contrast enhanced scan may aid in differential diagnosis and in the evaluation of lesion activity. T 2*-weighted imaging is useful to identify previous microbleeds, which usually occur in microvascular conditions and portend the risk of further bleeding. Proton spectroscopy, chemical shift imaging and diffusion weighted imaging have been shown to be very useful in some entities of white matter disease, both for differential diagnosis and the assessment of disease activity. They should hence be part of any advanced imaging protocol in patients with white matter disease. © Georg Thieme Verlag KG Stuttgart.

Successful management of post-TIPSS encephalopathy with a balloon-expandable covered stent: a controllable method to reduce shunt flow

Transjugular intrahepatic portosystemic shunt (TIPSS) is recognized as a useful technique in cases that fail to respond to two endoscopic sessions after acute variceal bleeds. TIPSS has been shown to be as effective in managing acute gastric bleeds as in managing acute oesophageal bleeds. The major complications of TIPSS procedures are shunt insufficiency and hepatic encephalopathy. New or worsened hepatic encephalopathy after TIPSS has been seen in up to 35% of cases, and it has been reported to be refractory to conservative medical treatment in up to 7% of cases, in whom further intervention has been necessary to reduce flow through the TIPSS. This may be performed by occluding the shunt completely or by using one of a variety of endovascular devices aimed at reducing the calibre of the stent lumen, which increases the portosystemic pressure gradient across the stent and improves intrahepatic portal bloodflow. Such techniques often improve the encephalopathy, but they may increase the risk of variceal bleeding, requiring a fine balance between the two. In this article, we describe a method to increase the portosystemic pressure gradient across the shunt in a controllable way, thus reducing encephalopathy but also minimizing the risks of further bleeding.

Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

Background & Aims: Endoscopic therapy reduces the rebleeding rate, the need for surgery, and the mortality in patients with peptic ulcer and active bleeding or visible vessel. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second hemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates, and mortality remain unclear. The aim of this study was to perform a systematic review and meta-analysis to determine whether the addition of a second procedure improves hemostatic efficacy and/or patient outcomes after epinephrine injection. Methods: An extensive search for randomized trials comparing epinephrine alone vs. epinephrine plus a second method was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2002. Selected articles were included in a meta-analysis. Results: Sixteen studies including 1673 patients met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.4% to 10.6% (Peto odds ratio 0.53, 95% CI: 0.40–0.69) and emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46–0.90). Mortality fell from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31–0.84). Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups, although reduction was more evident in high-risk patients and when no scheduled follow-up endoscopies were performed. Conclusions: Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery, and mortality in patients with bleeding peptic ulcer.

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial

Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomized, multicenter trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n = 1070) or endovascular treatment by detachable platinum coils (n = 1073). Clinical outcomes were assessed at both 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale (mRs) score between 3 and 6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. One hundred and ninety of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) of those allocated neurosurgical treatment ( P = .0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial

Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomised, multicentre trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n=1070) or endovascular treatment by detachable platinum coils (n=1073). Clinical outcomes were assessed at 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale score of 3-6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. 190 of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) allocated neurosurgical treatment (p=0.0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.

Value of stigmata in decision-making in gastrointestinal haemorrhage

The stigmata of recent haemorrhage are endoscopically identified features that have a predictive value for the risk of further bleeding and thus help to determine which patients should receive endoscopic therapy. In conjunction with endoscopic features, clinical features related to the magnitude of bleeding and to patient co-morbidity have important independent effects on the risk of further haemorrhage. Stigmata have been best studied in the context of bleeding ulcers, the most common cause of upper gastrointestinal bleeding. Stigmata in ulcers are usually classified as active bleeding (spurting or oozing), a non-bleeding visible vessel, an adherent clot, a flat pigmented spot, or a clean base, in order of decreasing risk of further haemorrhage. Ulcer size and location may also affect the re-bleeding potential. Recent data suggest that both non-pigmented visible vessels and adherent clots have a higher risk of re-bleeding than was previously thought. The wide variation in prevalence and re-bleeding rates reported for various stigmata in the literature probably reflects variations in the definitions of stigmata and of re-bleeding, the vigour with which the ulcer bases are washed, the co-morbidity and ages of the patients, and the severity of bleeding encountered. Inter-observer agreement in the classification of stigmata is relatively poor and limits the utility of endoscopic features alone in making decisions regarding the management of patients with bleeding peptic ulcers. Imaging devices such as Doppler probes are being evaluated to refine the identification of underlying vessels and their re-bleeding potential, but the utility of these is currently uncertain. The findings of low-risk endoscopic stigmata in a haemodynamically and otherwise stable patient can in many cases allow out-patient management.

Risk factors for Variceal Bleeding

Variceal bleeding is the most serious complication of portal hypertension. It is seen in 50-60% of patients with cirrhosis. The mortality in patients wo develop gastroesophageal variceal bleeding is approximately one third. In patients who have never bled from esophageal varices, 30% will hemorrhage within one year after the diagnosis of varices. The risk of bleeding after the initial bleed has been reported in the literature to be between 50 and 80%. In addition, approximately one-half of all rebleeds occur within the first six weeks. Beyond the sixth week after the initial bleeding episode, the risk of further bleeding returns to the same level of risk as in patients who have never bled (i.e., 30% within one year). With these figures in mind, it is important to be aware of the risk factors for gastroesophageal variceal hemorrhage. This paper examines the risk factors that may help identify patients most likely to bleed or rebleed. Specifically, risk factors for: 1) initial bleeding 2) early rebleeding (bleeding within six weeks of the initial bleed) and 3) late rebleeding (greater than six weeks from the initial bleed) are discussed.

Variceal Bleeding.

Cirrhotic patients should receive an endoscopy. Those with medium to large varices identified by endoscopy should receive beta-blocker therapy. The initial episode of variceal bleeding should be managed with endoscopic therapy to control the acute bleeding and concurrent infusion of octreotide. Portal hypertension and liver disease should be fully evaluated after such an episode, and patients should be started on first-line treatment (endoscopic therapy and pharmacologic therapy) to reduce the risk of further bleeding. Patients who bleed again after first-line therapy, and those with persistent risk factors whose varices are not obliterated by first-line treatment should be considered for second-line treatment, which is variceal decompression with transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunt. For patients with end-stage liver disease, liver transplantation may be the most appropriate treatment option. The management of variceal bleeding leading up to transplantation depends on the severity of the bleeding and available expertise. Minimal therapy to bridge the patient to transplantation is the goal. Devascularization procedures are reserved for patients who are not candidates for decompression because of venous thrombosis.

Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage.

Most patients with acute upper gastrointestinal haemorrhage are managed conservatively or with endoscopic intervention but some ultimately require surgery to arrest the haemorrhage. We have conducted a population-based multicentre prospective observational study of management and outcomes. This paper concerns the subgroup of 307 patients who had an operation because of continued or recurrent haemorrhage or high risk of further bleeding. The principal diagnostic group was those with peptic ulcer. Of 2071 patients with peptic ulcer presenting with acute haemorrhage, 251 (12%) had an operative intervention with a mortality of 24%. In the non-operative group mortality was 10%. The operative intervention rate increased with risk score, ranging from 0% in the lowest risk categories to 38% in the highest. Much of the discrepancy between operative and non-operative mortality was explainable by case mix; however, for high-risk cases mortality was significantly higher in the operated group. In 78% of patients who underwent an operation for bleeding peptic ulcer there had been no previous attempt at endoscopic haemostasis. For patients admitted to surgical units, the operative intervention rate was about four times higher than for those admitted under medical teams. In patients with acute upper gastrointestinal haemorrhage operative intervention is infrequent and largely confined to the highest-risk patients. The continuing high mortality in surgically treated patients is therefore to be expected. The reasons for the low use of endoscopic treatment before surgery are not revealed by this study, but wider use of such treatments might further reduce the operative intervention rate. Physicians and surgeons have not yet reached consensus on who needs surgery and when.