Severe Upper Gastrointestinal Bleeding Research Articles

Proton Pump Inhibitor for Gastrointestinal Bleeding in Patients with Myocardial Infarction on Dual-Antiplatelet Therapy: A Nationwide Cohort Study.

Guidelines provide various recommendations for the use of proton pump inhibitors (PPI) to prevent upper gastrointestinal (UGI) bleeding in acute myocardial infarction (MI) treatment with dual antiplatelet therapy (DAPT). We evaluated the effects of PPIs in reducing the risk of severe UGI bleeding in patients with MI receiving DAPT. This retrospective cohort study included patients admitted for acute MI between 2014 and 2018, based on a nationwide health claims database in Korea. Primary outcome was admission for severe UGI bleeding requiring transfusion within 1 year of MI diagnosis. A multivariable Cox regression model was used to calculate the association between PPI use and severe UGI bleeding risk. Of 100,556 patients with MI on DAPT (mean age, 63.7 years; 75.4% men), 37% were prescribed PPIs. Based on risk assessment for UGI bleeding, among 6,392 (6.4%) high-risk and 94,164 (93.6%) low-risk patients, 50.5% and 35.8% received PPIs, respectively. Overall, 0.5% of the patients experienced severe UGI bleeding within 1 year after MI. The use of PPI was associated with a reduced risk of severe UGI bleeding (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.47-0.70; P < 0.001). The benefits of PPIs were consistent in high-risk (HR, 0.71; 95% CI, 0.45-1.13; P = 0.147) and low-risk (HR, 0.54; 95% CI, 0.43-0.68; P < 0.001) patients (P for interaction = 0.481). Among Korean patients with MI receiving DAPT, PPIs were underutilized, even among those at high risk of severe UGI bleeding. Nonetheless, PPI use reduced severe UGI bleeding in low- and high-risk groups.

Clinical case: severe upper gastrointestinal bleeding and covid-19

La hemorragia digestiva alta en pacientes con COVID-19 es inusual y puede llegar a ser mortal. Se describe en hasta un 13 % de los pacientes hospitalizados con coronavirus. El tratamiento endoscópico es un desafío para el paciente debido al riesgo de insuficiencia respiratoria, como para el personal de salud debido al riesgo de transmisión aérea. Presentamos un caso clínico atípico de hemorragia digestiva alta grave por COVID-19.

Pancreatic head cancer with gastrointestinal bleeding as the initial manifestation: a case report and literature review

Gastrointestinal bleeding (GIB) as the initial symptom is rare in patients with pancreatic cancer, which is prone to misdiagnosis and should be paid attention to by clinicians. Here, we present a patient with pancreatic head cancer whose first symptom was only severe upper gastrointestinal bleeding, which initially led to misdiagnosis. However, subsequent imaging revealed a mass in the pancreatic head which was considered a malignant tumor. After surgical resection, the pathology confirmed that the mass in the pancreatic head was pancreatic ductal adenocarcinoma, and the duodenal bulb’s full thickness was infiltrated. A literature review found that pancreatic cancer can present gastrointestinal bleeding by invading the digestive tract and blood vessels, left-sided portal hypertension (LSPH), digestive tract metastasis, and canceration of ectopic pancreatic tissue in the digestive tract. For these cases, clinicians should utilize multidisciplinary diagnosis and treatment based on digestive endoscopy, imaging, interventional therapy, and surgery to control bleeding, identify etiology, and remove tumors.

Gastrointestinal Bleeding in COVID-19-Infected Patients.

COVID-19 infection is an ongoing catastrophic global pandemic with significant morbidity and mortality that affects most of the world population. Respiratory manifestations predominate and largely determine patient prognosis, but gastrointestinal (GI) manifestations also frequently contribute to patient morbidity and occasionally affect mortality. GI bleeding is usually noted after hospital admission and is often one aspect of this multisystem infectious disease. Although the theoretical risk of contracting COVID-19 from GI endoscopy performed on COVID-19-infected patients remains, the actual risk does not seem to be high. The introduction of PPE and widespread vaccination gradually increased the safety and frequency of performing GI endoscopy in COVID-19-infected patients. Three important aspects of GI bleeding in COVID-19-infected patients are (1) GI bleeding is often from mucosal erosions from mucosal infalammation that causes mild GI bleeding; (2) severe upper GI bleeding is often from PUD or stress gastritis from COVID-19 pneumonia; and (3) lower GI bleeding frequently arises from ischemic colitis associated with thromboses and hypercoagulopathy from COVID-19 infection. The literature concerning GI bleeding in COVID-19 patients is presently reviewed.

Efficacy of Tranexamic Acid in the Treatment of Massive Upper Gastrointestinal Bleeding: A Randomized Clinical Trial.

Background Upper gastrointestinal bleeding (GIB) is an important cause of emergency ward admission. Antifibrinolytic agents including tranexamic acid (TXA) have been used for controlling GIB. However, there have been concerns regarding the safety and efficacy of TXA in patients with GIB. Thus, in this study, we aimed to determine the efficacy of TXA in the treatment of massive upper GIB. Methodology This double-blind randomized clinical trial was conducted among 86 consecutive patients who were referred to Imam Hossein Hospital in Tehran, Iran from 2018 to 2019 with the chief complaint of massive upper GIB. Patients were chosen to be in the TXA or placebo groups based on a 1:1 allocation using the block randomization method. The rate of rebleeding, need for blood transfusion, hospital stay, adverse effects, and mortality rate were evaluated and compared across the groups. Results Of the 86 patients enrolled in this study, 55.8% (n = 48) were males. The mean age of all patients was 53.1 ± 10.6 years (TXA group: 54.9 ± 11.5 years, and placebo group: 51.4 ± 9.7 years). Rebleeding was seen in 11(25.6%) patients in the TXA group and in 20 (46.5%) patients in the control group, which was statistically significant (p = 0.043). Blood transfusion was carried out in only three (7%) patients in the TXA group compared with 14 (32.6%) patients in the placebo group (p = 0.003). Six (14%) patients experienced a hospital stay of longer than five days in the TXA group and 15 (34.9%) patients in the control group, which was statistically significant (p = 0.024). There were no significant differences in the mortality rate across both groups (p > 0.05). Conclusions TXA has no effect on mortality associated with severe upper GIB. However, it was associated with a lower rate of rebleeding and hospitalization time, without significant adverse effects.

Vitamin-K Antagonists vs. Direct Oral Anticoagulants on Severity of Upper Gastrointestinal Bleeding: A Retrospective Analysis of Italian and UK Data.

Background: Gastrointestinal bleeding (GIB) is one of most frequent and significant challenges for emergency physicians and gastroenterologists. Mortality for upper (U) GIB is high, especially in the elderly and comorbid patients. However, there is scant evidence in the literature concerning an assessment of warfarin (VKA) and direct oral anticoagulants (DOACs) in terms of upper gastrointestinal bleeding (UGIB) severity. Aims: Using data from two different settings (Italy and the UK), we aimed to compare the impact of VKA and DOACs on the severity of UGIB. Methods: Retrospective bicentric study on adult patients under VKA or DOACs admitted either to the emergency department at the Gemelli Hospital in Rome, Italy or University College Hospital in London, UK, with suspected UGIB from 01/01/2017 to 31/12/2018. Univariate analysis with Fisher's exact test, and analysis of variance (ANOVA) were used. Results: 106 patients (62 M/44 F; mean age 71.2 ± 16.9 yrs) were enrolled and divided into the VKA group (N = 57; M: 56%, mean age: 64.9 ± 21.3 yrs) and the DOAC group (N = 49; M: 61%; mean age: 77.6 ± 12.5 yrs). At univariate analysis, the VKA group presented two endoscopic diagnoses more frequently than the DOAC group (26% vs. 8%, p &lt; 0.05), were more frequently endoscopically treated (44% vs. 22%, p &lt; 0.05), rescoped (12% vs. 2%, p = 0.048) and hospitalized (79% vs. 53%, p = 0.01) with a longer length of stay, LOS (VKA: 58% &gt; 5 days vs. DOAC: 68% &lt; 5 days, p = 0.01). There was no difference in terms of hemoglobin level on admission, however the requirement of blood transfusions was higher in the VKA group (60% vs. 41%, p = 0.041). One third of the VKA group showed a lower platelet count than the DOAC group (33% vs. 8%, p = 0.01). No statistically significant differences for in-hospital mortality were observed. For the ANOVA, the type of anticoagulant used was the only significant predictor of need to rescope (p = 0.041) and a significant co-predictor for a LOS &gt; 5 days (p = 0.009; as well as cirrhosis, p = 0.013 and age, p = 0.005). Conclusions: Our outcomes revealed a more severe UGIB in patients on VKA, but the impact of comorbidities (i.e., more cirrhotic patients in the VKA group) cannot be disregarded. DOAC subgroup descriptive analysis, even though on a little cohort, showed higher bleeding severity for rivaroxaban.

S2592 Ethical Decision Making in Endoscopic Treatment of a Jehovah’s Witness With Severe Upper Gastrointestinal Bleeding

Introduction: For endoscopic procedures, informed consent elevates patient autonomy and circumvents medical paternalism. However, when procedures carry significant risk of harm, clinicians may unintentionally overlook patient preferences when making decisions. We present the case of a Jehovah’s Witness with upper gastrointestinal bleeding who was offered endoscopic intervention despite a high risk of peri-procedural mortality, with emphasis placed on the shared-decision making process. Case Description/Methods: A 77-year-old female Jehovah’s Witness presented with hematemesis and hemoglobin of 4.9 grams/deciliter (g/dL). Endoscopy demonstrated a duodenal ulcer with a visible vessel. Due to the inability to transfuse blood and risk of provoking further bleeding, the decision was made to forego clipping or cauterization and treat only with hemostatic powder (Figure 1). On hospital day 3 she experienced new melena with decrease in hemoglobin to 2.8 g/dL. Although providers were hesitant to offer repeat endoscopy given her lack of hemodynamic reserve, a nuanced discussion with the patient elucidated her wish to undergo all possible interventions even at high risk of death (Figure 2). Endoscopy was performed despite low hemoglobin, which redemonstrated the duodenal ulcer with a large pulsatile visible vessel. The ulcer was injected with epinephrine and an over-the scope clip was successfully placed (Figure 3). She initially stabilized, however on hospital day 5 she developed recurrent melena with hemodynamic instability. After discussion with her family, she was transitioned to comfort care measures and expired that evening. Discussion: When faced with the possibility of patient harm, gastroenterologists may intentionally withhold interventions due to a desire to act in what is perceived to be in the best interest of the patient. Ethically, however, acting by omission devalues both patient autonomy and the right to self-determination in care. This effect may be amplified by pre-existing stigma such as with the Jehovah’s Witness wherein refusal of blood products may be erroneously interpreted to imply a broader refusal of other life-saving treatments. In this case, through juxtaposition of two procedures, we demonstrate that this phenomenon can be circumvented via thoughtful discussion of all potential options with patients, regardless of physician preference. We hope to highlight the importance of this ethical concept when approaching patients for informed consent.Figure 1.: Ulcer with visible vessel on initial endoscopy, treated only with hemostatic powder. (2) Four-box model approach to ethical decision making in this case. (3) Same ulcer on repeat endoscopy, now with a pulsatile visible vessel, treated with an over-the-scope clip.

Risk of drug-related upper gastrointestinal bleeding in the total population of the Netherlands: a time-trend analysis

ObjectiveMany prescribed and over-the-counter medications, for example, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with upper gastrointestinal bleeding (UGIB). Recently, a decrease in prescribing of NSAIDs was observed in the Netherlands,...

Non-vitamin K antagonist oral anticoagulants, proton pump inhibitors and gastrointestinal bleeds

ObjectiveTo evaluate if proton pump inhibitor (PPI) treatment reduces the risk of upper gastrointestinal bleeding (UGIB) in patients with atrial fibrillation (AF) treated with non-vitamin K antagonist oral anticoagulants (NOACs).DesignWe...

Severe upper gastrointestinal bleeding is halted by endoscopically delivered self-propelling thrombin powder: A porcine pilot study.

Background and study aims Hemostatic powders have emerged recently to treat upper gastrointestinal bleeding (UGIB). Previously, we developed a novel self-propelling thrombin powder (SPTP) that effectively manages external pulsatile arterial bleed without compression, by effervescing and carrying thrombin into the wound. Here, we tested if SPTP, sprayed endoscopically, can manage severe UGIB in a live porcine model. Materials and methods Anesthetized pigs underwent laparotomy to insert the gastroepiploic vascular bundles into the stomach lumen via a gastrotomy. Bleeding was initiated endoscopically in the stomach by needle knife. SPTP was delivered to the site of bleeding from a CO 2 -powered spray device using a 7 FR catheter. Successful primary hemostasis, time to hemostasis, and the mass of SPTP delivered were measured. Results Hemostasis was achieved at all bleeding sites using SPTP. Mean time to hemostasis was 4.2 ± 0.9 minutes (mean ± standard error of the mean, n = 12). The average mass of SPTP delivered was 2.4 ± 0.6 g. Conclusions In this pilot study, SPTP successfully stopped 12 cases of severe UGIB, demonstrating early promise asa novel hemostatic powder.

Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis.

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

A surgically treated case of severe upper gastrointestinal hemorrhage with gastritis cystica polyposa

BackgroundGastritis cystica polyposa (GCP) is a recently recognized entity histologically characterized by hyperplasia and cystic dilatation of the gastric glands spreading through the submucosal layer. Its symptoms include those affecting the upper gastrointestinal tract, such as upper abdominal pain, nausea, and anorexia, although some patients might be asymptomatic. GCP rarely causes severe hemorrhage. Recently, we encountered a GCP case that exhibited severe hemorrhage.Case presentationA 53 year-old man visited the emergency department complaining of hematemesis. He underwent distal gastrectomy and Billroth II reconstruction for duodenal ulcers 32 years ago. Upper gastrointestinal endoscopy detected bleeding from the reddened mucosa at the anastomosis; thus, tentative endoscopic hemostasis was conducted. Despite medical treatment with transfusion, melena with significant hemodynamic impairment persisted. He was treated again with endoscopic hemostasis and interventional radiology (IVR) but remained unresponsive to these procedures. He eventually underwent partial resection of the anastomosis site with Roux-en-Y reconstruction and finally achieved excellent postoperative recovery. Histopathological examination of the resected specimen suggested a GCP bleeding.ConclusionsGCP can indeed cause severe hemorrhage. Hemorrhage caused by GCP may not respond to endoscopic hemostasis or IVR; therefore, surgical treatment should be decided without delay.

S1494 Gastroduodenal Artery Pseudoaneurysm in the Setting of Necrotizing Pancreatitis

INTRODUCTION: Gastroduodenal artery (GDA) pseudoaneurysms are a rare but fatal condition, representing about 1.5% of all visceral artery aneurysms.. If ruptured, mortality rate is high as 75%, particularly from severe upper gastrointestinal bleeding. Fortunately, the availability of imaging studies allows for early detection of these vascular events. Historically, they used to be treated either through surgical ligation or resection. Currently, minimally invasive endovascular procedures can be performed, resulting in a significant reduction in morbimortality. CASE DESCRIPTION/METHODS: 41 year old female with a history of Roux en Y gastric bypass, pancreatic divisum, chronic pancreatitis complicated by necrotic fluid collections was admitted for severe protein calorie malnutrition. She had a G tube place that persistently leaked, requiring a J arm for nutrition. Her hospital course was further complicated by peritonitis and serratia bacteremia, for which she received intravenous antibiotics. Six days after placement of her J arm, she began to have worsening epigastric pain. She became tachycardic up to the 140s. Abdominal exam was soft with epigastric tenderness without rebound or guarding. Labs were notable for new leukocytosis to 23 and a hemoglobin reduction from 8 to 6.6. CT imaging showed gastrostomy tube migration outside the stomach remnant, with spillage of gastric contents in the peritoneum. In addition to the known complicated necrotizing pancreatitis, the scan revealed a new development of a GDA pseudoaneurysm, 2 cm in size. Surgery was consulted to reposition the gastrostomy tube. Interventional radiology was also consulted for urgent GDA pseudoaneurysm coiling. Patient’s hemoglobin stabilized to her baseline the following days. DISCUSSION: Hemorrhagic complications of pancreatitis are rarely seen. Typically, patients with GDA pseudoaneurysms are asymptomatic or have non-specific abdominal pain. If ruptured, mortality rate is high as 75%. Fortunately, the availability of imaging studies allows for early detection of these vascular events. Gold standard diagnostic test is visceral angiography which provides both diagnostic and therapeutic value and has a 100% sensitivity. CT imaging is noninvasive and has a 67% sensitivity. Historically, they used to be treated either through surgical ligation or resection. We now are able to perform minimally invasive endovascular procedures, resulting in a significant reduction in morbimortality.Figure 1.: Gastroduodenal artery pseudoaneurysm (red arrow), 2cm in size, with surrounding complicated necrotizing pancreatitis.Figure 2.: Transcatheter selective embolization via coiling of the gastroduodenal artery pseudoaneurysm.

430 BALLOON TAMPONADE UTILIZATION FOR SEVERE ESOPHAGITIS CAUSING HEMORRHAGIC SHOCK

Abstract Esophagitis as a cause of upper gastrointestinal bleeding (UGIB) is a difficult entity to treat and is associated with significant morbidity. Epidemiologic studies note a 7-18% incidence of significant hemorrhage due to esophagitis. Current existing treatment options for UGIB complicated by hemorrhagic shock secondary to severe esophagitis are limited when there is a lack of response to proton pump inhibitor (PPI) medical therapy. Methods We present a case series of two patients who developed hemorrhagic shock from esophagitis, underwent endoscopic evaluation revealing limited treatment options, and ultimately required balloon tamponade resulting in successful resolution of bleeding and improvement in hemodynamics. A 55-year-old male with history of alcoholism complicated chronic pancreatitis and esophagitis presented with seizures. On admission he experienced hemorrhagic nasogastric tube output, anemia unresponsive to transfusions and hemodynamic instability. A 44-year-old patient with decompensated alcoholic cirrhosis was initially admitted for renal failure, and during the hospitalization developed melena and hemorrhagic shock requiring transfusions and vasopressors. The patients were promptly started on PPI infusion. Results Both patients underwent esophagogastroduodenoscopy revealing severe bleeding esophagitis extending from the gastroesophageal junction to the proximal esophagus and no varices. Active bleeding was not amenable to endoscopic therapy and both patients underwent balloon tamponade placement. The first patient required inflation of both the esophageal and gastric balloons for control of hemorrhage for 6 hours whereas the second patient required just gastric balloon inflation for 12 hours. Bleeding, transfusion requirement, and hemodynamics improved in both patients. Second look endoscopy demonstrated resolution of bleeding and hemostatic spray was applied to the esophagus prophylactically. Neither patient had recurrence of bleeding during the hospitalization. Conclusion UGIB secondary to esophagitis is difficult to control due to the highly vascularized nature of the esophagus. Endoscopic therapies are limited in extensive mucosal injury and risks of complications such as perforation are high. Other therapeutic options such as angiography are restricted due to vascular collateralization and surgical interventions have high morbidity and mortality. Balloon tamponade provides a viable treatment option for severe UGIB secondary to esophagitis that is not responsive to medical therapy.

Acute upper gastrointestinal bleeding in southern Saudi Arabia: A retrospective observational study

Context: Upper gastrointestinal bleeding (UGIB) is a common life-threatening emergency that carries considerable mortality and morbidity; it remains a common cause for admission to hospitals worldwide. UGIB is classified as variceal bleeding and non-variceal bleeding because of distinct etiologies and management. Aims: To describe present clinical manifestations in southern Saudi Arabian UGIB patients, including both endoscopic and basic laboratory parameters, to assess the risk factors, and compare the predictive power and clinical usefulness of three risk scoring systems (AIMS65 score, Glasgow-Blatchford score, Rockall risk score) for the management of patients presenting with UGIB. Methods: This was a retrospective observational study. We included 283 patients admitted to the gastrointestinal unit at Abha city, southern Saudi Arabia, from November 2017 to October 2019. The study findings were the etiology of UGI bleeding, the endoscopic findings and clinical outcome of UGI bleeding. Results: Ages ranged from 18 to 97 years old with mean age of 54.5 ± 18.5 years. The majority of patients were males (72%; 203). Melina was the most common presenting symptom, in 66 (49.3%) patients. Diabetes mellitus was the most frequently recorded risk factor for UGIB (53.9%) followed by hypertension (44.9%), and aspirin use (35.7%). Endoscopic hemostatic treatment was applied in 70 patients (24.7%); 4.9% of patients re-bled, and 21 patients (7.4%) died during the study period. Conclusions: Comorbidities such as hypertension and diabetes, in addition to some medicines including ASA, steroids and NSAIDs were identified as risk factors of upper GIT bleeding among this study casesa list of risk factors for severe UGIB, leading to hospitalization and even death.

Management of severe upper gastrointestinal bleeding in the ICU.

Upper gastrointestinal bleeding (UGIB) is a common condition that can lead to significant morbidity and mortality. Critical care physicians usually get involved in the care of patients with severe UGIB that is associated with hemodynamic compromise. We aim to provide the readers with evidence-based review of the management of patients with severe UGIB. Proton pump inhibitors are the main pharmacologic intervention for UGIB, along with adequate resuscitation and timely endoscopic intervention. Endoscopic therapy should be performed as soon as haemodynamics stabilization is achieved, which requires team collaboration. Several radiologic interventions are now commonly used as a second-line intervention after endoscopy. The management of severe UGIB requires multidisciplinary collaboration, prompt recognition and resuscitation, carful use of blood products, early correction of coagulopathy, and early endoscopic or radiologic interventions.

Gastric carcinoma: Insights into risk factors, methods of diagnosis, possible lines of management, and the role of primary care.

Gastric carcinoma represents the second most common type of malignancy that contributes to cancer-related mortality worldwide. However, the geographic incidence of gastric carcinoma had changed over the last few decades, possibly due to increased hygiene, increased awareness of the importance of healthy nutrition, and increased rates of eradication of Helicobacter pylori infection. Gastric carcinoma consists of two pathological variants, intestinal and diffuse. Early cases of gastric carcinoma may be asymptomatic. However, advanced cases may present with significant weight loss, dysphagia, abdominal pain, vomiting, and even severe upper gastrointestinal bleeding. Patients at high risk of developing gastric carcinoma should be adequately screened at primary healthcare centers for early detection and effective management. Lines of treatment vary according to the stage of the disease but surgical resection of the tumor with regional lymphadenectomy remains the gold standard of therapy. This review sheds light on gastric carcinoma given the recent trends regarding its prevalence, risk factors, types, clinical picture, methods of diagnosis, possible lines of management, and the role of primary care.

Tranexamic Acid for Upper Gastrointestinal Bleeding.

Upper gastrointestinal bleeding is common and accounts for at least half of the nearly 500,000 annual U.S. hospitalizations for gastrointestinal bleeding.1 In the acute setting, severe bleeding is treated with intravenous fluids, blood products, antiulcer therapy, and hemostasis by endoscopy.2 Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce bleeding.3, 4 TXA has been proven to be effective in improving patient-centered outcomes after severe hemorrhage due to trauma.5 The authors of this systematic review sought to evaluate the benefit of TXA administration specifically for upper gastrointestinal bleeding. The systematic review summarized here6 identified eight randomized trials of TXA in 1,701 subjects presenting with acute upper gastrointestinal bleeding among patients admitted to the hospital, including some in the intensive care unit. Two comparisons were made: TXA versus placebo and TXA versus antiulcer therapy (cimetidine or lansoprazole). Primary outcomes were mortality and adverse events. Compared to placebo, TXA reduced mortality (relative risk [RR] = 0.60, 95% CI = 0.42 to 0.87, ARR = 3.5%, NNT = 30, moderate-quality evidence). However, because of a high attrition in several trials the results must be interpreted with caution. About 20% of the studied patients were withdrawn or excluded for reasons such as lack of confirmation of the presence of bleeding, presence of malignancy, terminal illness, or late administration of treatments. Reanalysis including all participants and considering missing patients as treatment failures did not show mortality benefit.5 In the second comparison, TXA versus antiulcer therapy (cimetidine or lansoprazole), only two trials were included, and no mortality benefit was found. Administration of TXA did not reduce the risk of rebleeding (RR = 0.72, 95% CI = 0.50 to 1.03, low-quality evidence) or blood transfusion (RR = 1.02, 95% CI = 0.94 to 1.11, very-low-quality evidence). Although meta-analysis could not be performed for harm endpoints due to lack of adverse event reporting for all trials, three studies did include data on thromboembolic events. There was no difference between the TXA and placebo groups in combined serious thromboembolic events (myocardial infarction, pulmonary embolism, and cerebral infarction; RR = 1.37, 95% CI = 0.36 to 5.28), nor did TXA increase the risk of deep vein thrombosis (RR = 2.32, 95% CI = 0.60 to 8.89). The authors of this Cochrane review judged the available evidence to be of moderate to low quality, largely due to the risk of bias and clinical heterogeneity among included trials. Notably, the trials were conducted over nearly four decades (from 1973 to 2011), with six of eight published between 1973 and 1987, likely accounting for much of the heterogeneity. A high dropout rate was also concerning. When this was accounted for (in a worst-case scenario), the mortality benefit was not significant. The included trials also used different doses and routes of administration for TXA and were mostly performed 30 to 45 years ago. Management patterns, hemostatic technology, and cointerventions have since changed, in some cases dramatically, making applicability to current practice questionable. Finally, all trials enrolled admitted patients. Previous trials have shown that TXA is most efficacious when administered early (within 1 hour).5 Therefore, the delay in administration of TXA might have reduced efficacy, further reducing applicability and generalizability for ED patients. We have assigned a color recommendation of yellow (unclear benefits) to this intervention. Limitations of the reported data, particularly the lost to follow-up and dropout rates, the high risk of bias, and the presence of significant heterogeneity justify this rating. A large pragmatic double-blind controlled trial with a target sample size of 12,000 subjects is currently ongoing.7 We are hopeful this trial will provide better evidence. Despite TXA's lack of demonstrated benefit compared to standard treatments with respect to the endpoints of mortality or rebleeding, given the relative safety, lack of significant adverse events, and low cost of the medication, it may be reasonable to consider TXA in severe upper gastrointestinal bleeding as an adjunct to standard therapy or if standard therapy fails.

Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: A systematic review and meta-analysis.

Background and AimProphylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta‐analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB.MethodsEMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian‐Laird random effects models were used to calculate the inverse variance‐based weighted, pooled treatment effect across studies.ResultsSeven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01–6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26–1.67), and pneumonia (OR 6.58, 95% CI: 4.91–8.81]) compared to endoscopy without intubation. The LOS‐related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962–10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486–8432). There was no difference in risk of cardiovascular events after sensitivity analysis.ConclusionProphylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.

Evaluation of a Possible Effect of In-House Cryoprecipitate Transfusion on Outcome of Severe Upper Gastrointestinal Bleeding: A Retrospective Cohort Study

Purposes: Hypofibrinogenemia is usually complicated with severe and massive upper gastrointestinal (GI) bleeding, especially in liver cirrhosis. In Japan, neither fibrinogen concentrate nor cryoprecipitate (CRYO) is available for cases of acquired hypofibrinogenemia to recover the hemostatic level of fibrinogen rapidly. We prepared and produced in-house CRYO from fresh frozen plasma, and compared mortality between pre-implementation and post-implementation of CRYO. Methods: We performed a retrospective cohort study of patients admitted to our single tertiary medical center with upper GI bleeding from January 2011 to December 2016. The observational control period was from January 2011 to February 2013. From March 2013 to December 2016, we implemented the transfusion of CRYO, which was prepared and produced in our hospital. Clinical outcomes were compared between the patients in the two periods. Patients: Eleven patients in the control period and 10 in the intervention period were eligible for analysis. Results: In-hospital mortality (55% vs. 20%, P = 0.238) and mortality within 24 hour after admission (27% vs. 0%, P = 0.246) tended to be lower in the intervention period than in the control period, although the patients had more severe coagulation on admission than those in the control period. The plasma fibrinogen level before the treatment of hemostasis in the intervention period was higher than that in the control period (80 ± 9 mg/dL vs. 127 ± 15 mg/dL, P Conclusion: Implementation of in-house CRYO transfusion may reduce the rate of mortality due to severe upper GI bleeding.