Significant Gastrointestinal Bleeding Research Articles

Epinephrine Dose Has a Preventive Effect on the Occurrence of Stress Ulcer-Induced Gastrointestinal Bleeding in Critically Ill Patients.

Epinephrine may impair splanchnic blood flow, but the impact of epinephrine dose on the occurrence of clinically significant gastrointestinal bleeding (CSGB) caused by stress ulcer remains unclear. We investigated the effect of epinephrine dose on the occurrence of stress ulcer-related CSGB in intensive care unit (ICU) patients. In this prospective, observational, cohort study conducted in a French teaching hospital, 40 consecutive ICU patients receiving epinephrine infusion in whom a stress ulcer was diagnosed by an upper gastrointestinal endoscopy were included, from February 2010 to July 2015. The effects of epinephrine dose, and other covariates, on the occurrence of stress ulcer-related CSGB were analyzed using a multiple logistic regression model for repeated measures: At each observation, each patient serves as his own control. A total of 1484 time-dependent epinephrine dose modifications were available for analysis. The median epinephrine dose rate was 0.8 (0-9.5) mg/h, and the median epinephrine cumulative dose was 44.8 (2.6-2343) mg. Epinephrine, expressed as the average dose per day at time t, had a significant protective effect on the occurrence of stress ulcer (odds ratio 0.22; 95% confidence interval (CI), 0.12-0.38; p < 0.0001, for a log10 increase of epinephrine dose). Enteral feeding had also a protective effect (odds ratio 0.55; 95% CI 0.41-0.72; p < 0.0001, for a log10 increase of kcal/day). Only renal replacement therapy increased the occurrence of stress ulcer in the model. An increase in the average dose of epinephrine per day increased the time to occurrence of stress ulcer in critically ill patients.

864 SUCCESSFUL EUS-GUIDED TREATMENT OF GASTRIC VARICES WITH COIL EMBOLIZATION AND INJECTION OF ABSORBABLE GELATIN SPONGE

Gastric varices occur in 15-20% of patients with portal hypertension and are associated with significant gastrointestinal bleeding and high mortality. Endoscopic options are currently limited in patients with bleeding gastric varices. Here, we report our experience with endoscopic ultrasound-guided coil embolization and injection of absorbable gelatin sponge for the treatment of gastric varices. A 51 year old female with alcoholic cirrhosis, complicated by ascites, hepatic encephalopathy, and known type 1 gastric varices, presents to the hospital with hematemesis. She was deemed by interventional radiology to not be a suitable candidate for either transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO). It was therefore decided to offer EUS-guided treatment of her gastric varices. On EUS, four large collections of gastric varices were visualized, each with multiple individual compartments measuring 7-12 mm in short axis. Multiple varices were seen to directly contact the surface of the fundus. Using a 19 gauge EUS needle, a collection of gastric varices was punctured, followed by deployment of multiple 20 mm x 14 cm and 20 mm x 7 cm embolization coils. Following coil embolization, there was immediate obliteration of Doppler flow. After multiple coils were deployed, and contrast injections ruled out the presence of a gastrorenal shunt, additional injection was performed of absorbable gelatin sponge (prepared as a slurry) in order to further enhance variceal eradication. The process was then repeated until all four collections of gastric varices were eradicated. In total, eight vascular coils were deployed. The patient tolerated the procedure well and has not had recurrent bleeding on follow-up. EUS guided coil embolization and injection of absorbable gelatin sponge is a feasible and effective technique for the endoscopic management of symptomatic gastric varices in patients considered to be poor candidates for standard treatments such as TIPS and BRTO. This case highlights the advantages of coil embolization and absorbable gelatin sponge application, as well as the benefit of EUS guidance, over traditional direct cyanoacrylate injection for the endoscopic management of gastric varices.

Prevention of upper gastrointestinal bleeding in critically ill Chinese patients: a randomized, double-blind study evaluating esomeprazole and cimetidine

Objective: To assess the efficacy and safety of esomeprazole in preventing upper gastrointestinal (GI) bleeding in critically ill Chinese patients, using cimetidine as an active comparator.Methods: A pre-specified non-inferiority limit (5%) was used to compare rates of significant upper GI bleeding in this randomized, double-blind, parallel-group, phase 3 study across 27 intensive care units in China. Secondary endpoints included safety and tolerability measures. Patients required mechanical ventilation and had at least one additional risk factor for stress ulcer bleeding. Patients were randomized to receive either active esomeprazole 40 mg, as a 30-min intravenous (IV) infusion twice daily, and an IV placebo cimetidine infusion or active cimetidine 50 mg/h, as a continuous infusion following an initial bolus of 300 mg, and placebo esomeprazole injections, given up to 14 days. Patients were blinded using this double-dummy technique.Results: Of 274 patients, 2.7% with esomeprazole and 4.6% with cimetidine had significant upper GI bleeding (bright red blood in the gastric tube not clearing after lavage or persistent Gastroccult-positive “coffee grounds” material). Non-inferiority of esomeprazole to cimetidine was demonstrated. The safety profiles of both drugs were similar and as expected in critically ill patients.Conclusions: Esomeprazole is effective in preventing upper GI bleeding in critically ill Chinese patients, as demonstrated by the non-inferiority analysis using cimetidine as an active control.Trial registration: ClinicalTrials.gov identifier NCT02157376.

Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Risk factors associated with clinically significant gastrointestinal bleeding in pediatric ED

IntroductionGastrointestinal bleeding is a common problem in pediatric emergency department (PED). Some of these patients can lose significant amount of blood which may lead to shock. The aim of this study is to determine the risk factors predicting clinically significant gastrointestinal (GIS) bleeding in patients presenting to PED. MethodsThis study was performed prospectively from January 1st 2013 to December 31th 2013 in patients with upper or lower GIS bleeding. Clinically significant GIS bleeding was defined as >2g/dL hemoglobin decrease at any time during observation in PED, need for erythrocyte transfusion or need for rapid endoscopic evaluation. Results105 patients were enrolled, 81 of which were eligible for the study. Twenty two patients (26,8%) had clinically significant GIS bleeding. These patients have significantly more commonly have upper GI bleeding and symptoms of melena, pallor and tachycardia. Initial laboratory findings revealed lower hemoglobin, RBC and albumin levels with higher WBC and BUN levels. They need significantly more nasogastric tube placement and PPI and H2 blocker treatment. Final diagnosis included more gastritis and peptic ulcers. These patients have less hematochezia, less lower gastrointestinal bleeding and less commonly diagnosed as acute gastroenteritis or Mallory Weiss tear as a final diagnosis. ConclusionsPediatric emergency physicians should be aware of clinical and laboratory parameters of patients with clinically significant GIS bleeding to predict which patients are under risk of life threatening blood loss. Patients who have melena, pallor, tachycardia, anemia and uremia at presentation are more prone to have significant GIS bleeding.

A Rare Case of Gastrointestinal Histoplasmosis in an Immunocompromised Host

Introduction: Histoplasmosis capsulatum (HC) is a dimorphic fungus common to the Ohio and Mississippi River valleys and is found mainly in soil enriched by avian or bat droppings. It typically presents as an asymptomatic pulmonary infection. Gastrointestinal (GI) involvement is usually unrecognized due to nonspecific symptoms and is thought to be symptomatic in only 3 to 12% of patients. The majority of GI histoplasmosis involves patients with HIV/AIDS. The most common site of GI involvement is the ileocecal region due to the presence of abundant lymphoid tissue. Case Presentation: A 64-year-old man with paroxysmal atrial fibrillation (on warfarin), end stage renal disease on hemodialysis, status post failed transplanted kidney and on chronic immunosuppression presented with a one day history of hematochezia and hematemesis and six weeks of worsening left lower quadrant abdominal pain. CT thorax with intravenous contrast revealed a right lower lobe cavitary mass and a spiculated left upper lobe nodule (Figure 1). Esophagogastroduodenoscopy with enteroscopy revealed old blood in stomach and the endoscope was advanced into the jejunum revealing multiple ulcers (Figure 2). Histopathology from jejunal biopsies was consistent with HC (Figure 3). Histoplasmosis antibodies by complement fixation for yeast and mycelia were positive as was fungal immunodiffusion for Histoplasma M antigen. Histoplasmosis serum antigen was negative. The patient was treated with intravenous amphotericin for presumed disseminated histoplasmosis. He improved clinically with resolution of symptoms and was discharged on oral itraconazole and remains therapeutic five months later.Figure: CT thorax with intravenous contrast showing (A) 21mm right lower lobe cavitary mass (B) and 19mm left upper lobe spiculated nodule.Figure: Ulcerations of proximal (A) and mid-jejunum (B).Figure: Gomori methenamine silver (GMS) stain of jejunal biopsy specimen showing budding yeast form of histoplasmosis capsulatum.Discussion: Histoplasmosis capsulatum is generally seen in immunocompromised hosts. While common at autopsy, gastrointestinal histoplasmosis (GIH) goes unrecognized during life as the symptoms are nonspecific. Patients with GIH most commonly present with abdominal pain and diarrhea, but may also have dysphagia, odynophagia, bowel obstruction or perforation. In this case, the patient presented with clinically significant gastrointestinal bleeding. Upper endoscopy with jejunal biopsies revealed HC. Both the presence of symptomatic GIH and the jejunal location are atypical. This observation in a patient without HIV is exceedingly rare.

Systemic Octreotide Therapy in Preventionof Gastrointestinal Bleeds Related to Arteriovenous Malformations and ObscureEtiology in Atrial Fibrillation.

The present study describes the use of octreotide (OCT) in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC) who have gastrointestinal (GI) bleeding related to arteriovenous malformations (AVMs), as well as its effect on OAC tolerance and subsequent rebleeding. AVMs cause significant GI bleeding, especially in patients with AF who are receiving OAC for stroke prevention. OCT has been shown to minimize recurrent GI bleeds related to AVMs. In a multicenter, observational study, 38 AF patients with contraindications to OAC because of AVM-related GI bleeding were started on 100 μg of subcutaneous OCT twice daily. OAC was resumed in all patients within 48 h. Incidence of recurrent GI bleeds was calculated, and hemoglobin levels were recorded at enrollment and at 3 and 6months' follow-up. After a median follow-up of 8 months, 36 patients (mean age 69 ± 8.0 years; mean CHA2DS2-VASc score 3±1 and mean HAS-BLED score 3 ± 1) were available for analysis. All were able to successfully resume OAC, and 28 of 36(78%) remained on OAC at the conclusion of the study, whereas 8 underwent left atrial appendage closure with subsequent OAC discontinuation. No systemic thromboembolic events occurred in follow-up. Of the 28 patients who continued receiving OAC, 19 (68%) were free of recurrent GI bleed, 4 had minor GI bleeds, 4 required transfusion, and1required colectomy for GI bleeding. Mean hemoglobin levels in all patients receiving OAC were significantly higher at 3- and 6-month follow-up than at baseline (p< 0.001). Subcutaneous OCT therapy is an attractive option in AF patients receiving OAC who have AVM-related GI bleeds. It allows successful reinitiation of OAC as a bridge to left atrial appendage exclusion or short-term relief frombleeding.

Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study

PurposeWe investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients. Materials and methodsProspective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups. Results124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99). ConclusionWe found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.

Comparison of the efficacy of intravenous tranexamic acid with and without topical administration versus placebo in urgent endoscopy rate for acute gastrointestinal bleeding: A double-blind randomized controlled trial.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, is effective as a treatment for serious hemorrhage, including bleeding arising from major trauma and post-operative interventions. Significant acute gastrointestinal bleeding may have a poor outcome despite routine medical and endoscopic treatments. The aim of this study was to assess whether early intravenous and/or intravenous plus topical administration of TXA reduces the need for urgent endoscopy for acute gastrointestinal bleeding. This double-blind randomized clinical trial included 410 patients with proven acute gastrointestinal bleeding. All patients received conventional therapy. The subjects were randomized to three groups: (A) 138 patients received intravenous TXA (1 g q6h); (B) 133 patients received topical TXA (1 g single dose by nasogastric tube) plus systemic TXA; and (C) 139 patients received a placebo (sodium chloride 0.9%) for 24 hours. Subgroup statistical analyses were conducted for urgent endoscopy, mortality, re-bleeding, blood transfusion, endoscopic and/or surgical intervention rates, and health status. The time to endoscopy was significantly shorter in group C (15.58 ± 7.994, p < 0.001). A need for urgent endoscopy was seen in 14.49%, 10.52%, and 30.21% of patients in groups A, B, and C, respectively (p < 0.001). No significant statistical differences were seen between treatment groups regarding mortality, re-bleeding, blood transfusion, and endoscopic and/or surgical intervention rates. No thromboembolic event was documented during the 1-week follow up. Our results showed that the antifibrinolytic properties of TXA can aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients.

Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indications, Benefits, and Infectious Complications.

Acid-suppressive therapy for prophylaxis of stress ulcer bleeding is commonly prescribed for hospitalized patients. Although its use in select, at-risk patients may reduce clinically significant gastrointestinal bleeding, the alteration in gastric pH and composition may place these patients at a higher risk of infection. Although any pharmacologic alteration of the gastric pH and composition is associated with an increased risk of infection, the risk appears to be highest with proton pump inhibitors, perhaps owing to the potency of this class of drugs in increasing the gastric pH. With the increased risk of infection, universal provision of pharmacologic acid suppression to all hospitalized patients, even all critically ill patients, is inappropriate and should be confined to patients meeting specific criteria. Nurses providing care in critical care areas may be instrumental in screening for appropriate use of acid-suppressive therapy and ensuring the drugs are discontinued upon transfer out of intensive care or when risk factors are no longer present.

Efficacy and safety of edoxaban for treatment of portal vein thrombosis following danaparoid sodium in patients with liver cirrhosis

To compare the efficacy and safety of edoxaban and warfarin for treatment of portal vein thrombosis (PVT) following danaparoid sodium in patients with liver cirrhosis. Fifty cirrhotic patients with PVT treated initially for 2weeks with danaparoid sodium were enrolled in this retrospective cohort study. Treatment was later switched to either edoxaban (n = 20) or warfarin (n = 30). We compared the efficacy and safety of edoxaban and warfarin for up to 6months. The PVT volume was measured by dynamic computed tomography before treatment, at 2weeks, and at 1, 3, and 6months. There were no significant differences in the clinical characteristics of patients in the two groups. Treatment with edoxaban reduced the volume of PVT from 1.42cm3 at 2weeks to 0.42cm3 at 6months, and prevented exacerbation of PVT at 6months after treatment with danaparoid sodium (P = 0.016). In contrast, treatment with warfarin resulted in increased PVT volume from 1.73cm3 at 2weeks to 2.85cm3 at 6months, despite the control of the international normalized ratio in 57% of the patients (P = 0.005). Multivariate regression analysis identified edoxaban therapy as the single significant and independent determinant of PVT reduction at 6months (P = 0.0014, hazard ratio 6.400). Clinically significant gastrointestinal bleeding was encountered in 3 of 20 (15%) patients of the edoxaban group and 2 of 30 (7%) of the warfarin group (P = 0.335). Edoxaban following danaparoid sodium is an effective anticoagulant and could be potentially considered as one of the treatment options for PVT in cirrhotic patients.

We No Longer Need to Stress Ulcer Prophylaxis in the Critically Ill

Preventing stress gastropathy has been a mainstay in the management of critically ill patients for decades. A landmark trial in 1994 identified the most significant risk factors for stress gastropathy as mechanical ventilation for greater than 48 h and primary coagulopathy. Since this study's publication more than two decades ago, the incidence of clinically significant gastrointestinal bleeding secondary to stress gastropathy has significantly declined. In addition, the most widely used agents for prophylaxis have been associated with an increasing number of adverse effects, including myocardial infarction, Clostridium difficile infection, osteoporosis and ventilator associated pneumonia. As the incidence of significant bleeding decreases and the knowledge about prophylaxis-related adverse events increases, it is necessary to revisit current clinical practice. Major practice changes, including early aggressive fluid resuscitation and development of dynamic markers for volume status, have reduced the likelihood for prolonged hypoperfusion states. Additionally, the recognition of the important of enteral nutrition early in the ICU stay encourages mesenteric perfusion and reduces risk for development of ischemic damage. Contemporary studies have failed to replicate significant rates of gastrointestinal bleeding, likely in part due to these advances in care. Recent studies, including a pilot randomized trial, are questioning the necessity of pharmacologic prophylaxis in the modern era, with undetectable rates of gastrointestinal bleeding in enrolled patients. Patients with risk factors for stress gastropathy who demonstrate no evidence of splanchnic hypoperfusion may not benefit from receiving stress ulcer prophylaxis and tolerance of enteral nutrition may be used as a surrogate marker for adequate perfusion. Overall there is a lack of high quality data supporting stress ulcer prophylaxis in the modern era.

Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition.

Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. A retrospective cohort study of records from 2008 to 2013. Adult patients in a single-center STICU were included. Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized. Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

Effect of Gastric Acid Suppressant Prophylaxis on Incidence of Gastrointestinal Bleeding in Pediatric Intensive Care Unit

Background: Critically ill children admitted to pediatric intensive care unit (PICU) are at increased risk of gastrointestinal bleeding due to stress related mucosal injury. Reducing gastric acid by acid suppressant medication is the accepted prophylaxis treatment, but there is not any definitive guideline for using prophylaxis in PICU patients. The present study aimed to assess the effect of Proton Pump Inhibitor (PPI) and H2 Blocker (H2B) prophylaxis on gastrointestinal bleeding in admitted patients of PICU, Mashhad- Iran.Materials and Methods: In this study, 100 patients admitted in PICU divided into two equal groups on the first day of admission. They received ranitidine or pantoprazole as prophylaxis of stress ulcer. Those patients who had history of gastrointestinal bleeding or coagulation disorder were excluded. 100 PICU patients who had not received prophylaxis during last 6 months retrospectively evaluated as control of the study. Data were collected as demographic characteristics, admission reason, definitive diagnosis, receiving corticosteroid and mechanical ventilation in each patient. Gastrointestinal bleeding (hematemesis, coffee ground aspirate, and melena) and clinically significant gastrointestinal bleeding were daily monitored. Data analyzed through descriptive statistical tests, Chi-square, logistic regression, t-test and using SPSS-16 software.Results: Among 204 patients (control group=105 and case group=99), incidence of gastrointestinal bleeding (GB) was 13.2% in which 6.9% of cases presented with clinically significant gastrointestinal bleeding (CSGB). Loss of consciousness and respiratory distress were the main reason of admission. There was no significant differences between the incidence of (GB) and (CSGB) in experimental and control groups (P>0.05) as well as ranitidine and pantoprazole prophylaxis (P>0.05). Significant risk factors of (GB) were mechanical ventilation and loss of consciousness and corticosteroid therapy.Conclusion: There is ambiguity about probable benefits of gastrointestinal bleeding prophylaxis in critically ill children. We proposed that prophylaxis should prescribe in patients with two or more risk factors of gastrointestinal bleeding.

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study.

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration. Prospective randomized double-blind parallel-group study. University-affiliated mixed medical-surgical ICU. Mechanically ventilated critically ill patients suitable for enteral nutrition. We randomly assigned patients to receive either daily IV placebo or pantoprazole. Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06). We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.

Reversal of GI Bleeding with Idarucizumab in a Patient on Dabigatran and Incidental Finding of a Retroperitoneal Hematoma

Introduction: The increase in use of anticoagulation has led to the development of many new drugs that target improved compliance. Because these drugs increase the risk of bleeding, the availability of reversal agents has become an important aspect when considering their prescription. We present a case of a 78 year old male on Dabigatran who presented with gastrointestinal (GI) bleeding from a marginal ulcer and was successfully treated with Idarucizumab. Case: Our patient is a 78 year old male with a history of atrial fibrillation (on Dabigatran), recent panreatectomy with Roux-en-Y reconstruction for intraductal papillary mucinous neoplasm who presented to the hospital with an episode of bloody bowel movement, dizziness and weakness. He had a pulse of 107 bmp and blood pressure of 91/44 mmHg. His physical exam was pertinent for lethargy and blood per rectum. Pertinent laboratory findings included creatinine of 1.2 mg/DL, hemoglobin of 11.1 g/dL and PTT of 86.6. Upon arrival to the emergency department, he was resuscitated with 1 L normal Saline and his BP improved to 118/55 mmHg. Since he was having a hemodynamically significant GI bleed, he was given Idarucizumab to reverse the anticoagulant effect. Subsequent lab findings revealed a PTT of 48 and hemoglobin of of 8.3 g/dL. Patient had an EGD which revealed patent enteroenterostomy characterized by congestion, erythema, friable mucosa, inflammation and ulceration, and evidence of extrinsic compression on the posterior stomach wall. CT scan of the abdomen showed a 19.7 cm x 9.1 cm x 8.0 cm heterogeneous collection of fluid in the retroperitoneal area. He subsequently went for a laparotomy and had evacuation and suturing of the bleeding splenic artery. Discussion: Dabigatran remains one of the safest new oral anticoagulant agents as it has a reversal agent recently FDA approved for life threatening bleeds. In our patient, the GI bleed was a direct consequence of his recent pancreatectomy with Roux-en-Y reconstruction as evident from the marginal ulceration and inflammation seen on EGD. His GI bleed subsequently resolved with eventual normalization of PTT signifying reversal of the affect of Dabigatran. What makes this case more interesting is the incidental discovery of a large retroperitoneal hematoma based on the extrinsic compression of the stomach found on EGD. This serves as a great reminder to always consider a retroperitoneal bleed in an anticoagulated patient with a recent GI surgery.

Pattern of upper gastrointestinal bleeding at Rahim Yar Khan

Design: It is a Prospective Observational case series. Place and Duration of Study: The study was conducted at Sheikh Zayed Hospital/Hamza Medicare Rahim Yar Khan, between January 1997 and December 2004. Patients and Methods; Consecutive 892 patients presenting with significant gastrointestinal bleeding, between January 1997 and December 2004 were recruited in this study. Source of active bleeding was defined by endoscopy. Results: Esophageal variceal bleed was the main finding 580, followed by gastric erosions 133 patients, Esophageal Ulcer 65, duodenal ulcer 61, bleeding gastric ulcer (26), Mallory Weiss Tear 21 and Osler Weber Rendu Syndrome/AV malformation 06 only. Conclusion: Esophageal varices are-real problem within our area but the scope has changed in the western world. Variations in disease pattern from time to time require the periodic studies to be aware of the current underlying mechanism of the ailments in the area of work. Total reliance on literature may consume local resources.

World Gastroenterology Organisation Global Guidelines: GERD Global Perspective on Gastroesophageal Reflux Disease.

PROBIOTICS—THE CONCEPTHistory and DefinitionsA century ago, Elie Metchnikoff (a Russian scientist, Nobel laureate, and professor at the Pasteur Institute in Paris) postulated that lactic acid bacteria (LAB) offered health benefits capable of promoting longevity. He suggested that “intestinal autoint

Gastrointestinal angiodysplasia is associated with significant gastrointestinal bleeding in patients with continuous left ventricular assist devices.

Background and study aims: Patients with a continuous-flow left ventricular assist device (LVAD) have a 65 % incidence of bleeding events within the first year. The majority of gastrointestinal bleeding (GIB) is from gastrointestinal angiodyplasia (GIAD). The primary aim of the study was to determine whether GIAD was associated with a higher rate of significant bleeding, an increased number of bleeding events per year, and a higher rate of transfusion compared to non-GIAD sources. Patients and methods: This retrospective cohort study included 118 individuals who received a LVAD at a tertiary medical center from 2006 through 2014. Patients were subdivided into GIB and non-GIB for comparison of patient demographics, comorbid conditions, and laboratory data. GIB was further divided into sources of GIB, GIAD, obscure, or non-GIAD to establish severity of bleeding, rate of re-bleeding, and transfusion rate. Results: GIAD is associated with an increased number of bleeding events compared to non-GIAD sources of GIB (2.07 vs 1.23, P = 0.01) and a higher number of bleeding events per year (0.806 vs. 0.455 P = 0.001). GIAD compared to non-GIAD sources of GIB was associated with an increased incidence of major bleeding (100 % vs 60 %, P = 0.006) and increased rates of transfusion (8.8 vs 2.95 units, P = 0.0004). Cox Regression analysis between non-GIB and GIAD demonstrated increased risk with age (P = 0.001), history of chronic kidney disease (P = 0.005), and length of stay after LVAD implantation of more than 45 days (P = 0.04). History of hypertension (P = 0.045), diabetes mellitus (P = 0.016), and male gender was associated with decreased risk (P = 0.04). Conclusion: Patients with a continuous-flow LVAD who develop a GIB secondary to GIAD have a higher rate of major bleeding, multiple bleeding events, and require more transfusions to achieve stabilization compared to patients who do not have GIAD.

Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding.

Background/Aims:Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency that can be life threatening. This study evaluated predictive factors of 30-day mortality in patients with this condition.Methods:A prospective observational study was conducted at a single hospital between April 2010 and November 2012, and 336 patients with symptoms and signs of gastrointestinal bleeding were consecutively enrolled. Clinical characteristics and endoscopic findings were reviewed to identify potential factors associated with 30-day mortality.Results:Overall, 184 patients were included in the study (men, 79.3%; mean age, 59.81 years), and 16 patients died within 30 days (8.7%). Multivariate analyses revealed that comorbidity of diabetes mellitus (DM) or metastatic malignancy, age ≥ 65 years, and hypotension (systolic pressure < 90 mmHg) during hospitalization were significant predictive factors of 30-day mortality.Conclusions:Comorbidity of DM or metastatic malignancy, age ≥ 65 years, and hemodynamic instability during hospitalization were predictors of 30-day mortality in patients with NVUGIB. These results will help guide the management of patients with this condition.