Source Of Upper Gastrointestinal Bleeding Research Articles

Assessing the Predictive Factors for Bleeding in Esophageal Variceal Disease: A Systematic Review.

Esophageal varices, dilated submucosal distal esophageal veins, are a common source of upper gastrointestinal bleeding in patients with portal hypertension. This review aims to comprehensively assess predictive factors for both the first occurrence and subsequent risk of esophageal variceal bleeding. A systematic search was conducted in PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Cochrane databases. A total of 33 studies were selected using rigorous inclusion and exclusion criteria. The risk of bias was assessed using the Newcastle-Ottawa Scale. Several predictive factors were identified for esophageal variceal bleeding, including the Child-Pugh score, Fibrosis Index, specific endoscopic findings, ultrasound parameters, portal vein diameter, presence and size of collaterals, CT scan findings, ascites, platelet counts, coagulation parameters, albumin levels, Von Willebrand Factor, bilirubin levels, diabetes mellitus, and the use of b-blocking agents in primary prophylaxis. The findings of this systematic review shed light on multiple potential predictive factors for esophageal variceal bleeding. Endoscopic findings were found to be reliable predictors. Additionally, ultrasound parameters showed associations with bleeding risk. This systematic review identifies multiple potential predictive factors for esophageal variceal bleeding in patients with portal hypertension. While certain factors exhibit strong predictive capabilities, further research is needed to refine and validate these findings, considering potential limitations and biases. This study serves as a critical resource for bridging knowledge gaps in this field.

Nature and treatment outcomes of bleeding post-bulbar duodenal ulcers.

Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in-hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs. This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location.

Upper Gastrointestinal Bleeding

Despite continued advances in therapeutic endoscopy and potent medications to suppress acid production, upper gastrointestinal bleeding (UGIB), defined as bleeding that occurs proximal to the ligament of Treitz, continues to be a common reason for surgical consultation. UGIB results in considerable use of hospital resources, and carries a 2 to 14% mortality. This review covers presentation and initial management, clinical evaluation, risk stratification, investigative tests, and discussion and management of specific sources of UGIB. Figures show an algorithm for management of bleeding from duodenal or gastric ulcers, a technique for duodenotomy and three-point ligation of a bleeding duodenal ulcer, anatomic locations of gastric ulcers according to the modified Johnson classification, and an algorithm for management of bleeding from esophageal or gastric varices. Table list the Glasgow Blatchford prediction score for UGIB, the AIMS65 prediction score for UGIB, the Rockall prediction score for UGIB, and the Forrest classification for stigmata of recent hemorrhage used to evaluate bleeding ulcers and prevalence data for each class. This review contains 4 highly rendered figures, 4 tables, and 91 references

S2609 Direct Invasion of Hepatocellular Carcinoma as an Unusual Source of Upper Gastrointestinal Bleeding

S2609 Direct Invasion of Hepatocellular Carcinoma as an Unusual Source of Upper Gastrointestinal Bleeding

Validation of a decision rule to predict patients at low risk of variceal upper gastrointestinal hemorrhage.

Determining the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides ED therapy, but can be difficult to determine on clinical grounds. A simple decision rule, using only platelet and international normalized ratio (INR) values, was previously derived in a single center and had high sensitivity (97%). We sought to validate this decision rule using multi-center data. We performed this decision rule validation using data collected from 21 Canadian hospitals, comprising 2020 patients. The parent study enrolled patients aged ≥18years at participating hospitals with nonvariceal or variceal UGIB from January 2004 through May 2005. To validate the existing decision rule, we computed the test characteristics of the rule on this study population. The existing decision rule, in order to predict patients at low risk for variceal hemorrhage, is designed to be highly sensitive for variceal UGIB. In the previously derived rule, patients are not low risk if either is present: INR ≥1.3 or platelet count ≤200×109/L. We additionally added a third common-sense criterion to the decision rule in a separate analysis: whether the patient has previously had variceal hemorrhage. 2001 patients were eligible for analysis, including 214 (10.7%) with a variceal source of gastrointestinal hemorrhage. Median age was 69 (IQR 55-79), and 764 (38%) were women. The two-step rule correctly identified 204 of the 214 (95.3%) patients with variceal hemorrhage; adding prior variceal hemorrhage as a variable identified 5 more patients (209/214 [97.7%]). Of the 2001 patients, 953 (47%) would have been classified as low risk for variceal hemorrhage; of these patients, 5 (0.5%) experienced variceal hemorrhage. The sensitivity of the rule in this validation cohort was 95.3% (95% CI 91.6-97.7%), with a negative likelihood ratio of 0.09 (95% CI 0.05-0.16). Adding prior variceal hemorrhage increased sensitivity to 97.7% (95% CI 94.6-99.2%), with a negative likelihood ratio of 0.04 (95% CI 0.02-0.11). We have validated a simple decision rule to identify patients at low risk for variceal UGIB. This two-step (three-step if prior history of variceal hemorrhage is known) rule is simple to use, and may enable safe deferment of unnecessary or harmful therapies.

Upper Gastrointestinal Bleeding.

Although its incidence is decreasing, upper gastrointestinal bleeding represents a significant cause of morbidity and mortality. We present the most common sources of upper gastrointestinal bleeding and treatments.

2008 Fundic Gland Polyps: Not Always an Innocent Bystander

INTRODUCTION: Fundic gland polyps (FGP) are often found incidentally on endoscopy in 1.9% of patients, with most being asymptomatic. However, as in this case, FGP have been a source of upper gastrointestinal bleeding (UGB) leading to hospitalization. CASE DESCRIPTION/METHODS: An 81-year-old male with GERD and non-dysplastic Barrett’s Esophagus, presented to the emergency department with coffee ground emesis for 2 weeks. He denied NSAID, steroid, or alcohol use. GERD is well controlled on Omeprazole 40 mg daily which he has taken for the past 10 years. He denies dysphagia, abdominal pain or weight loss. No family history of gastric or colon cancer or familial polyposis syndromes. Patient with normal heart rate and blood pressure however with orthostatic hypotension. Physical exam without abdominal tenderness and rectal vault without stool on exam. Hemoglobin 11.1 on presentation with last hemoglobin 13.3 four months ago. Last EGD 2 years ago revealed non-dysplastic Barrett’s Esophagus, along with a few sub centimeter non-bleeding FGP, confirmed with biopsy. A colonoscopy 4 years prior had one tubular adenoma. Patient underwent EGD and was found to have multiple gastric body polyps; several of the largest polyps had active oozing blood. The bleeding polyps measured 12 mm in size and were removed via hot snare polypectomy. Normal remainder of exam. Afterward he remained clinically stable with no further bleeding and was discharged with Omeprazole daily. Histology revealed FGP with low grade dysplasia. H.pylori was negative on biopsies. Repeat EGD 8 weeks later removed the remaining polyps and gastric mapping was performed. Histology revealed FGP without dysplasia and no gastric intestinal metaplasia was noted. Patient has done well since with no further bleeding. DISCUSSION: Bleeding gastric FGP are rarely considered in the differential of UGB, however in this case, led to the patient’s hospitalization. Long-term (&gt;5 years) proton-pump inhibitors (PPI) have been associated with fourfold increased risk of FGP, with regression often seen upon withdrawal of PPI. This patient brings a unique case in which guidelines recommend long-term daily PPI for his Barrett’s Esophagus, however has already had complications from his growing FGP on Omeprazole. FGP can also be associated with polyposis syndromes. Malignancy is rare in sporadic and PPI induced FDG but can be seen in up to 4.2% of patients with familial adenomatous polyposis. The removal of FGP can potentially limit the risk of future bleeding as seen in this case.

Spontaneous Rupture of a Pseudoaneurysm of the Right Hepatic Artery Causing Massive Upper Gastrointestinal Bleeding.

We describe the case of an 84-year-old woman who presented with right lower chest pain, anaemia and newly deranged liver function which was followed by massive upper gastrointestinal (GI) bleeding with no source of bleeding found on upper GI endoscopy. CT angiography of the GI tract confirmed rupture of a pseudoaneurysm of the right hepatic artery (RHA) that was treated successfully with trans-arterial embolization of the RHA.LEARNING POINTSIf upper gastrointestinal (GI) endoscopy fails to identify the source of upper GI bleeding, CT angiography is required to search for rare causes such as pseudoaneurysm of the right hepatic artery (RHA) with fistula formation with the GI and biliary tract, along with other causes such as aorto-enteric fistula.Pseudoaneurysm of the RHA is commonly secondary to recent surgery or trauma and spontaneous occurrence is very rare.Endovascular repair using transcatheter arterial embolization is the treatment of choice but if it fails, emergency laparotomy should be considered.

Endoscopic findings and outcomes of upper gastrointestinal bleeding patients in northern Iran population referred to the emergency department

Gastrointestinal bleeding is one of the reasons that patients referred to the emergency department. In the majority of these patients, the bleeding stops spontaneously but some of them are high risk patients who may experience complications and may need endoscopic and surgical treatment. Mismanagement of these cases leads to high mortality. Different studies evaluated the causes of Upper GI bleeding but there is not any information about the distribution of these reasons in north of Iran. Methods and material. This prospective study included patients with history of upper gastrointestinal bleeding between January 2017 and December 2018. A total of 224 patients underwent endoscopy for UGIB and the data were studied. Follow up was done for occurrence of re-bleeding or mortality. Results. Our study revealed that the most common cause of upper GI bleeding was duodenal ulcer and gastric ulcer. Antrum was the main anatomical site for gastric ulcer. After the 15 days follow up in 17 (6.8 %) patients mortality existed and rebleeding was found in 11 (4.4 %) patients and the need for surgery in 3 (1.2 %) patients. Conclusions. Like many parts of the world the most common source of upper gastrointestinal bleeding in our study was peptic ulcer diseases. Our study revealed that despite all diagnostic and treatment procedures still there is mortality (6.8 % mortality existed) due to GI bleeding.

Identifying Emergency Department Patients at Low Risk for a Variceal Source of Upper Gastrointestinal Hemorrhage.

Assessing the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides therapy, but can be difficult to determine on clinical grounds. The objective of this study was to determine if there are easily ascertainable clinical and laboratory findings that can identify a patient as low risk for a variceal source of hemorrhage. This was a retrospective cohort study of adult ED patients with UGIB between January 2008 and December 2014 who had upper endoscopy performed during hospitalization. Clinical and laboratory data were abstracted from the medical record. The source of the UGIB was defined as variceal or nonvariceal based on endoscopic reports. Binary recursive partitioning was utilized to create a clinical decision rule. The rule was internally validated and test characteristics were calculated with 1,000 bootstrap replications. A total of 719 patients were identified; mean age was 55 years and 61% were male. There were 71 (10%) patients with a variceal UGIB identified on endoscopy. Binary recursive partitioning yielded a two-step decision rule (platelet count > 200 × 109 /L and an international normalized ratio [INR] < 1.3), which identified patients who were low risk for a variceal source of hemorrhage. For the bootstrapped samples, the rule performed with 97% sensitivity (95% confidence interval [CI] = 91%-100%) and 49% specificity (95% CI = 44%-53%). Although this derivation study must be externally validated before widespread use, patients presenting to the ED with an acute UGIB with platelet count of >200 × 109 /L and an INR of <1.3 may be at very low risk for a variceal source of their upper gastrointestinal hemorrhage.

Causes of Bleeding and Outcomes in Patients Hospitalized With Upper Gastrointestinal Bleeding

To evaluate sources of upper gastrointestinal bleeding (UGIB) at an urban US hospital and compare them to sources at the same center 20 years ago, and to assess clinical outcomes related to source of UGIB. Recent studies suggest changes in causes and outcomes of UGIB. Consecutive patients with hematemesis, melena, and/or hematochezia undergoing upper endoscopy with an identified source at LA County+USC Medical Center from January 2005 to June 2011 were identified retrospectively. Mean age of the 1929 patients was 52 years; 75% were male. A total of 1073 (55%) presented with hematemesis, 809 (42%) with melena alone, and 47 (2%) with hematochezia alone. The most common causes were ulcers in 654 patients (34%), varices in 633 (33%), and erosive esophagitis in 156 (8%), compared with 43%, 33%, and 2% in 1991. During hospitalization, 207 (10.7%) patients required repeat endoscopy for UGIB (10.6% for both ulcers and varices) and 129 (6.7%) died (5.2% for ulcers; 9.2% for varices). On multivariate analysis, hematemesis (OR=1.38; 95% CI, 1.04-1.88) and having insurance (OR=1.44; 95% CI, 1.07-1.94) were associated with repeat endoscopy for UGIB. Varices (OR=1.53; 95% CI, 1.05-2.22) and having insurance (OR=4.53; 95% CI, 2.84-7.24) were associated with mortality. Peptic ulcers decreased modestly over 2 decades, whereas varices continue as a common cause of UGIB at an urban hospital serving lower socioeconomic patients. Inpatient mortality, but not rebleeding requiring endoscopy, was higher with variceal than nonvariceal UGIB, indicating patients with variceal UGIB remain at risk of death from decompensation of underlying illness even after successful control of bleeding.

Helicobacter Pylori Infection in a Group of Egyptian Children With Upper Gastro-Intestinal Bleeding.

BackgroundUpper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage. Helicobacter pylori (H. pylori) is a Gram negative spiral-shaped bacterium that is found in the gastric mucous layer or adherent to the epithelial lining of the stomach. It causes more than 90% of duodenal ulcers and up to 70-80% of gastric ulcers. The relationship between H. pylori infection and upper GIT bleeding in children is still un-clear. This study aimed to estimate the incidence of H. pylori infection in children presented with upper GIT bleeding and correlation between H. pylori infection and endoscopic findings of the cause of bleeding.MethodsThe study included 70 children presented with upper GIT bleeding indicated for upper gastrointestinal endoscopy admitted in pediatric department, Minia University Hospital, Egypt during the period from February 2010 to December 2012. Thirty healthy children were included as a control group with age and sex matched. After medical history taking and physical examination all children were exposed for laboratory investigations (CBC, prothrombin time and concentration, liver function tests, hepatitis viral markers, blood urea and serum creatinine and Helicobacter pylori stool antigen test). Upper endoscopy was done for patients only. Patients were classified into variceal and non variceal groups according to upper endoscopy.ResultsHelico-pylori infection was significantly higher in children with non-variceal bleeding than controls (P = 0.02) and children with variceal bleeding (P = 0.03) with no significant difference between children with variceal bleeding and controls (P = 0.9). Both weights and BMIs centile were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 and 0.01 & 0.001 respectively). AST, ALT and direct bilirubin levels were significantly higher in variceal group than controls (P = 0.001, 0.004 & 0.001 respectively). Prothrombin concentration and albumin levels were significantly lower in variceal group than controls (P = 0.001 & 0.01 respectively). Hemoglobin levels were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 respectively). No significant differences were present as regards age, sex, height or platelets count between cases (variceal and non-variceal) and controls.ConclusionsH. pylori infection is significantly higher in children with non-variceal bleeding than controls. No significant difference between children with variceal bleeding and controls. Triad of increased ALT, decreased albumin levels and negative H. pylori infection could be a significant triad in predicting variceal bleeding as a cause of upper GIT bleeding in children.

Ectopic varices.

Ectopic varices.

Upper gastrointestinal bleeding in children: an 11-year retrospective endoscopic investigation

Upper gastrointestinal bleeding (UGIB) may present as hematemesis, coffee-ground emesis, or melena requiring esophagogastroduodenoscopy (EGD) for diagnosis and/or therapy. Worldwide, differences exist for the etiology of UGIB reflecting geographical differences in common disease states. In the past 25 years, there have been improvements in endoscopic optics. This study was undertaken to determine: 1) if identifying a bleeding source in UGIB have improved with better endoscopic optics, 2) geographic differences in causes of UGIB, 3) differences in severity of UGIB based on clinical factors, and 4) the likelihood of finding a bleeding source based on symptom duration and time to endoscopy. A retrospective chart review was made on children having EGD for evaluation of UGIB. Data collected included type, etiology, and degree of bleeding. Of 2569 diagnostic procedures, 167 (6.5%) were performed for UGIB. The most common presentation was hematemesis (73.4%). Melena was associated with lower hemoglobin levels and higher transfusion rates. A source of UGIB was found in 57.0%, no cause in 11.4% and a questionable cause in 29.7%. A source was found less commonly in children with a history of UGIB less than one month and in those undergoing endoscopy over 48 hours after a bleeding episode. Improved endoscopic optics has not changed diagnostic ability for UGIB. Etiologic differences for UGIB in children from varying geographic areas are related to indication for endoscopy, patient selection, and co-morbid conditions. Duration of bleeding and time to endoscopy after a bleeding episode may help predict when endoscopy should be performed to determine a bleeding source.

Clinical Profile and Outcome of Non-Variceal Upper Gastrointestinal Bleeding in Relation to Timing of Endoscopic Procedure in Patients Undergoing Elective Endoscopy

Background: Endoscopy is the most accurate method for diagnosing the source of upper gastrointestinal bleeding. This study was aimed to evaluate the correlation between the timing of elective endoscopy and the length of hospital stay, the amount of transfusion given and incidence of recurrent bleeding or patient mortality. Method: A retrospective study was conducted in all patients with non-variceal upper gastrointestinal bleeding who had experienced elective endoscopy at Cipto Mangunkusumo Hospital between January 2007 and August 2008. Identification of clinical risk using clinical Rockall score was performed at the emergency room. Persistent bleeding, recurrent bleeding, surgical treatment and death were the outcome variables. Statistical analysis was performed using Chi-square/fisher exact test and linear regression. Results: There were 40 eligible cases with mean age of 53 ± 13 years; the greatest occurrence was at the age group of 50-59 years (12%), male (52.5%) and those who had clinical symptom of melena (52.5%). Twenty seven (67.5%) patients had Rockall score of 1-3 points and 13 (32.5%) had 4-6 points. There was only one patient who had adherent clots (Forrest grade II B). Endoscopy results revealed that the most common cause of bleeding was gastric ulcer, which occurred in 12 (30%) patients. There was no correlation between the timing of endoscopic procedures and outcome variable; however the length of hospital stay had a significant correlation with timing of endoscopic procedures. Conclusion: Elective endoscopy does not affect the variables of mortality and recurrent bleeding; however, it affects the length of hospital stay. Further prospective studies are required to find causal relation between them. Keywords : non-variceal upper gastrointestinal bleeding, Rockall score, elective endoscopy, outcome variables

Helicobacter pyloriinfection in bleeding peptic ulcer patients after non-steroidal antiinflammatory drug consumption

To establish the prevalence of Helicobacter pylori (H. pylori) infection in patients with a bleeding peptic ulcer after consumption of non-steroidal antiinflammatory drugs (NSAIDs). A very early upper endoscopy was performed to find the source of upper gastrointestinal bleeding and to take biopsy specimens for analysis of H. pylori infection by the rapid urease (CLO) test, histological examination, and bacterial culture. IgG anti-CagA were also sought. The gold standard for identifying H. pylori infection was positive culture of biopsy specimens or contemporary positivity of the CLO test and the presence of H. pylori on tissue sections. Eighty patients, 61 males (76.3%), mean age 61.2 ± 15.9 years, were consecutively enrolled. Forty-seven (58.8%) patients occasionally consumed NSAIDs, while 33 (41.3%) were on chronic treatment with low-dose aspirin (LD ASA). Forty-four (55.0%) patients were considered infected by H. pylori. The infection rate was not different between patients who occasionally or chronically consumed NSAIDs. The culture of biopsy specimens had a sensitivity of 86.4% and a specificity of 100%; corresponding figures for histological analysis were 65.9% and 77.8%, for the CLO test were 68.2% and 75%, for the combined use of histology and the CLO test were 56.8% and 100%, and for IgG anti-CagA were 90% and 98%. The highest accuracy (92.5%) was obtained with the culture of biopsy specimens. Patients with a bleeding peptic ulcer after NSAID/LD ASA consumption frequently have H. pylori infection. Biopsy specimen culture after an early upper gastrointestinal tract endoscopy seems the most efficient test to detect this infection.

Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include variceal hemorrhage (most commonly extra-hepatic portal venous obstruction in our settings) and mucosal lesions (gastric erosions and ulcers secondary to drug intake). While most gastrointestinal bleeding may not be life threatening, it is necessary to determine the source, degree and possible cause of the bleeding. A complete and thorough history and physical examination is therefore vital. Esophagogastroduodenoscopy and colonoscopy are currently considered the first-line diagnostic procedures of choice for upper and lower GI bleeding, respectively. The goals of therapy in a child with GI bleeding should involve hemodynamic resuscitation, cessation of bleeding from source and prevention of future episodes of GI bleeding. Antacids supplemented by H2- receptor antagonists and proton pump inhibitors are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, therapeutic emergency endoscopy is the treatment of choice after initial hemodynamic stabilization of the patient. Independent prognostic factors are presence of shock and co-morbidities. Underlying diagnosis, coagulation disorder, failure to identify the bleeding site, anemia and excessive blood loss are other factors associated with poor prognosis.

Risk Factors for Mortality in Lower Intestinal Bleeding

Previous studies of lower intestinal bleeding (LIB) have limited power to study mortality. We sought to identify characteristics associated with in-hospital mortality in a large cohort of patients with LIB. We used the 2002 Healthcare Cost and Utilization Project Nationwide Inpatient Sample to study a cross-sectional cohort of 227,022 hospitalized patients with discharge diagnoses indicating LIB. Predictors of mortality were identified by using multiple logistic regression. In 2002, an estimated 8737 patients with LIB (3.9%) died while hospitalized. Independent predictors of in-hospital mortality were age (age >70 vs <50 years; odds ratio [OR], 4.91; 95% confidence interval [CI], 2.45-9.87), intestinal ischemia (OR, 3.47; 95% CI, 2.57-4.68), comorbid illness (>or=2 vs 0 comorbidities, OR, 3.00; 95% CI, 2.25-3.98), bleeding while hospitalized for a separate process (OR, 2.35; 95% CI, 1.81-3.04), coagulation defects (OR, 2.34; 95% CI, 1.50-3.65), hypovolemia (OR, 2.22; 95% CI, 1.69-2.90), transfusion of packed red blood cells (OR, 1.60; 95% CI, 1.23-2.08), and male gender (OR, 1.52; 95% CI, 1.21-1.92). Colorectal polyps (OR, 0.26; 95% CI, 0.15-0.45), and hemorrhoids (OR, 0.42; 95% CI, 0.28-0.64) were associated with a lower risk of mortality, as was diagnostic testing for LIB when added to the multivariate model (OR, 0.37; 95% CI, 0.28-0.48). Hospital characteristics were not significantly related to mortality. Predictors of mortality were similar in an analysis restricted to patients with diverticular bleeding. The all-cause in-hospital mortality rate in LIB was low (3.9%). Advanced age, intestinal ischemia, and comorbid illness were the strongest predictors of mortality.

Significance of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs in patients with bleeding from upper part of the gastrointestinal tract

Helicobacter pylori (H. pylori) infection and nonsteroidal anti-inflammatory drugs (NSAIDs) use are considered to be the most important risk factors having influence on the onset of bleeding gastroduodenal lesions. Whether there is an interaction between H. pylori infection and the use of NSAIDs in the development of peptic ulcer disease is still controversial. The aim of the present study was to evaluate the prevalence of NSAIDs use and H. pylori infection in patients presented with bleeding gastroduodenal lesions. During the period from January 2003 December 2003 we prospectively obtained data of all the patients (n=106) presented with signs of upper gastrointestinal bleeding. All the patients were admitted to the intensive care unit, with the endoscopy performed within 12 hours after admission. Histologic analysis was used for the detection of H. pylori infection. The NSAIDs and aspirin use data were obtained by anamnesis. The results of our study revealed that the most common sources of upper gastrointestinal bleeding were duodenal (57 patients, 53.77%) and ventricular (36 patients, 33.96%) ulcers. The majority of the examined cases were associated with both H. pylori infection and NSAIDs use. A statistically significant difference among the studied groups of patients was proven. The majority of bleeding gastroduodenal lesions were associated with the coexistance of H. pylori infection and NSAIDs use, while their independent influences were statistically less important. Eradication of H. pylori infection in patients using NSAIDs might prevent upper gastrointestinal hemorrhage and reduce peptic ulcer bleeding risk.

Dieulafoy’s lesion: Rare cause of massive upper gastrointestinal bleeding

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.