Acute upper gastrointestinal bleeding (AUGIB) is a critical clinical condition with high morbidity and mortality, necessitating effective therapeutic interventions. This study retrospectively investigated the efficacy of tranexamic acid combined with octreotide (OCT) in patients with high risk of AUGIB. A total of 183 patients with UGIB were initially enrolled, and 170 eligible patients were finally included and divided into an OCT group (n=83) and a TXA + OCT group (n=87). The main indicators compared were: drug onset time, hemostasis time, upper gastrointestinal bleeding volume, blood routine, coagulation function and clinical effective rate; secondary indicators: clinical efficacy, visual analogue scale (VAS) and adverse reactions. After treatment, the onset time, hemostasis time, bleeding volume, coagulation function indexes (PT, TT, APTT and Fib) and VAS in TXA group and OCT group were significantly lower than those in OCT group. The clinical effective rate and hemoglobin, red blood cell and platelet count in TXA group and OCT group were significantly higher than those in OCT group (P<0.05). There were no significant differences in the average blood transfusion volume, hospitalization time, rebleeding rate within 3 days, surgical intervention needs and mortality between the two groups (P>0.05), but the combined group had a slight advantage. In addition, combination therapy did not increase the incidence of adverse reactions. These findings provide valuable clinical evidence supporting the use of tranexamic acid in combination with octreotide for AUGIB.

Iron deficiency anemia unmasking an endoscopically resectable GIST

Although rare, stress-related gastrointestinal complications, such as perforated peptic ulcer (PPU) and upper gastrointestinal bleeding, can result in notable morbidity and mortality following orthopaedic surgery, particularly in elderly or critically ill patients. Despite widespread implementation of stress ulcer prophylaxis (SUP) in critical care, its role in orthopaedic surgical populations remains ill defined. A narrative review of the literature reveals a low incidence of PPU following orthopaedic procedures (0.054% after elective spine surgery); however, associated mortality may reach as high as 25% in cases of PPU. Identified risk factors include NSAID use, advanced age, notable comorbidities, and critical illness. SUP with proton pump inhibitors or histamine-2 receptor antagonists has been shown to reduce upper gastrointestinal bleeding in critically ill patients, leading to guideline-based recommendations for selective prophylaxis in high-risk individuals. Given the potential severity of these complications, orthopaedic surgeons should maintain vigilance and consider SUP in at-risk patients, while avoiding routine prophylaxis in low-risk cases. Tailoring prophylactic strategies to patient-specific risk factors aligns with best practices from critical care and may help mitigate preventable postoperative complications.

This guideline is an update of the 2021 ESGE Guideline on Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. The following are the new and/or revised recommendations. 1: ESGE does not recommend the routine use of video capsule endoscopy or telemetric blood-sensing capsules in the management of patients with suspected upper gastrointestinal hemorrhage (UGIH). 2: ESGE suggests, if intravenous erythromycin is unavailable, pre-endoscopy administration of intravenous metoclopramide in selected patients with clinically severe or ongoing active UGIH. 3: ESGE suggests that pre-endoscopy high dose intravenous proton pump inhibitor (PPI) therapy be considered in patients presenting with acute UGIH; however, this should not delay early endoscopy. 4: ESGE does not recommend emergent (≤6 hours) or urgent (≤12 hours) upper GI endoscopy unless the patient remains hemodynamically unstable despite adequate resuscitation. 5: ESGE suggests that patients with peptic ulcers presenting with an adherent clot (Forrest IIb) should undergo endoscopic therapy, with clot removal and subsequent endoscopic hemostasis if indicated, provided that the endoscopist has the technical competence to safely remove the clot and manage potential conversion to a higher risk bleeding lesion. 6: ESGE could not reach a consensus for or against the routine use of a Doppler endoscopic probe in treatment decisions of high risk endoscopic stigmata of peptic ulcer bleeding. 7: ESGE suggests the use of over-the-scope (OTS) clips as monotherapy as an alternative to combination therapy as first-line therapy for peptic ulcer bleeding with high risk stigmata (FIa, FIb) owing to a lower risk of further bleeding compared with standard endoscopic hemostatic therapy. 8: ESGE recommends, for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy (e.g. through-the-scope or OTS clips), or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. 9: ESGE suggests, for patients with an ulcer with a nonbleeding visible vessel (FIIa), OTS clips may be used as alternative monotherapy. 10: ESGE suggests hemostatic forceps with soft coagulation may be used as monotherapy in the treatment of peptic ulcer bleeding with high risk stigmata (FIa, FIb, and FIIa). 11: ESGE suggests that hemostatic agents should not be used as monotherapy in the first-line treatment of patients with high risk stigmata of peptic ulcer bleeding. 12: ESGE suggests that, in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic agent or OTS clips should be considered. 13: ESGE recommends that, in patients with persistent bleeding refractory to all modalities of endoscopic hemostasis, including topical hemostatic agents and OTS clips, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after unsuccessful TAE. 14: ESGE suggests that prophylactic TAE be considered in selected high risk cases of peptic ulcer bleeding (e.g. patients with hemodynamic instability at presentation, posterior duodenal wall ulcer location, large ulcer size [>2 cm], or when durable endoscopic hemostasis is considered uncertain). 15: ESGE could not reach a consensus for or against the routine use of potassium-competitive acid blockers for patients who have undergone endoscopic hemostasis. 16: ESGE recommends that, for patients with clinical evidence of recurrent peptic ulcer bleeding, use of an OTS clip should be considered. Should this second attempt at endoscopic hemostasis also be unsuccessful, TAE should be considered. Surgery is indicated when TAE is either locally unavailable or after unsuccessful TAE. 17: ESGE recommends that, in patients with peptic ulcer hemorrhage who require ongoing anticoagulation therapy, anticoagulation should be resumed as soon as clinically indicated based on thromboembolic risk. 18: ESGE suggests that iron therapy be initiated prior to hospital discharge in patients with peptic ulcer bleeding and iron deficiency and/or anemia. 19: ESGE suggests that early oral nutrition, within 24 hours following endoscopic hemostasis, be initiated in patients with peptic ulcer bleeding in whom durable hemostasis has been achieved.

Upper gastrointestinal bleeding (UGIB) remains a significant clinical emergency with substantial mortality. Accurate risk stratification is essential for optimal patient triage and management. The ABC score (Age, Blood tests, Comorbidities) and AIMS65 score are prominent pre-endoscopy risk stratification tools, yet direct comparative studies within diverse United States healthcare populations remain limited. To compare the predictive accuracy of ABC and AIMS65 scores for in-hospital mortality and secondary clinical outcomes in patients with acute UGIB. This retrospective cohort study analyzed 2,009 adult patients admitted with acute UGIB across multiple Northwell Health hospitals between January 2019 and January 2024. Both ABC and AIMS65 scores were calculated for each patient using structured EMR data, ICD-10 diagnosis codes, and anesthesiology procedure documentation. Primary outcomes included in-hospital mortality and 30-day readmission. Secondary outcomes encompassed hospital length of stay, ICU admission, development of complications (shock, sepsis, acute kidney injury), vasopressor use, and need for mechanical ventilation. Univariable logistic regression models assessed predictive accuracy using area under the receiver operating characteristic curve (AUC), with bootstrap internal validation (10,000 resamples) confirming negligible optimism bias. DeLong's test compared discriminative abilities between scores. Sensitivity analyses evaluated score performance across pandemic periods and in a broader AIMS65-computable cohort. Among 2,009 patients (56.1% male; median age 70 years), 97 (4.8%) experienced in-hospital mortality and 59 (2.9%) had 30-day readmission. The ABC score demonstrated significantly superior predictive accuracy for mortality compared to AIMS65 (AUC 0.793 vs. 0.661; p < 0.0001 by DeLong's test; optimism-corrected AUCs: 0.793 and 0.661, respectively). Each one-unit increase in ABC score corresponded to a 50.7% increase in mortality odds (OR 1.507; 95% CI: 1.386-1.638). Neither score significantly predicted 30-day readmission. ABC score showed stronger correlations with secondary outcomes including hospital length of stay (r = 0.47 vs. r = 0.33), ICU length of stay (r = 0.35 vs. r = 0.22), and vasopressor requirements (r = 0.30 vs. r = 0.21). ABC's superiority was consistent across pre-pandemic, peak pandemic, and post-peak subgroups. In the broader AIMS65-computable cohort (n = 6,766), AIMS65 demonstrated an AUC of 0.706, confirming that the cohort restriction modestly attenuated its discrimination but that ABC's advantage persisted. The ABC score demonstrates significantly superior predictive accuracy for in-hospital mortality compared to AIMS65 in patients with acute UGIB, with consistent advantages across secondary outcomes, pandemic periods, and cohort definitions. These findings support the preferential use of ABC score for risk stratification in clinical practice.

Gastric bleeding is amajor symptom of locally advanced gastric cancer and asignificant cause of mortality. Management options include surgery, endoscopic interventions, embolization and radiotherapy (RT). Although palliative RT appears effective for hemorrhage control, evidences are limited to underpowered retrospective studies from Asia, with issues of patient heterogeneity and response evaluation criteria. This study is amulticenter retrospective analysis carried out across Italian radiation oncology centers to evaluate real-world outcomes of hemostatic RT in patients with bleeding gastric cancer. Clinical and dosimetric data were retrospectively collected for patients with active bleeding gastric cancer treated across twelve Italian radiation oncology centers. The primary endpoint was to evaluate hemoglobin stabilization or improvement at four weeks post-treatment. Secondary outcomes included treatment parameters, acute toxicity profile and time to rebleeding. Between January 2018 and October 2024, 100 patients receiving hemostatic RT were collected for the analysis. The median age was 77years, 68% of cases had advanced disease and 41% of patients were pretreated with chemotherapy. The most frequently administered dose was 39 Gy BED10 (range: 9.6-53.1) with aschedule of 30 Gy in 10fractions. The primary endpoint was achieved in 95/100 patients (95%) indicating stabilization or improvement in Hb levels without the need for post-treatment transfusions. Only 12patients experienced acute toxicity, of whom 2 (3.3%) presenting grade3 nausea. Rebleeding symptoms occurred in 38.5% of cases (median interval of 164 days). This national, retrospective, multicenter study suggests that palliative gastric RT is afeasible, effective and well-tolerated approach in this cohort of patients with bleeding gastric cancer, providing hemostatic control and stabilizing hemoglobin levels. Prospective trials are warranted to better define the role of RT, particularly in terms of dose and fractionation based on the disease setting and patient characteristics.

Downhill esophageal varices due to superior vena cava (SVC) obstruction are a rare cause of upper gastrointestinal bleeding. An 87-year-old man presented with melena/hematemesis and severe anemia. Emergency endoscopy identified active bleeding from proximal downhill varices, controlled by endoscopic band ligation. Chest CT angiography demonstrated an SVC thrombus (3.7 × 9 mm) with a downstream short-segment high-grade stenosis/occlusion; venography confirmed complete short-segment occlusion at the level of cardiac resynchronisation therapy with defibrillator (CRT-D) leads. Because of the risk of compromising lead function, recanalization/thrombectomy was deferred and therapeutic anticoagulation (heparin, then apixaban) was initiated, with additional ligation of high-risk variceal columns on follow-up endoscopy. This case highlights the need for rapid CT angiographic evaluation for SVC obstruction in proximal varices, particularly in patients with intravascular devices.

Background: The clinical significance of Helicobacter pylori (H. pylori) infection in acute non-variceal upper gastrointestinal bleeding (NVUGIB) remains uncertain, particularly regarding short-term outcomes beyond rebleeding. Methods: We conducted a single-center retrospective cohort study of consecutive adults admitted with acute NVUGIB to Hatyai Hospital, Thailand, between January 2016 and December 2020. H. pylori status was determined during the index hospitalization using rapid urease testing and/or histopathologic examination of gastric biopsy specimens obtained during upper gastrointestinal endoscopy. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital mortality, rebleeding, requirement of packed red blood cell transfusion, and length of hospital stay. Multivariable regression analyses were performed to adjust for potential confounders. Results: Among 933 patients, 289 (31.0%) were H. pylori-positive and 644 (69.0%) were H. pylori-negative. The H. pylori-positive group was younger, predominantly male, and had lower rates of cirrhosis and prior proton pump inhibitor use. They also more often had peptic ulcer bleeding and underwent earlier endoscopy. H. pylori positivity was independently associated with lower 30-day mortality (adjusted odds ratio 0.39, 95% confidence interval 0.18–0.84), but not with rebleeding, requirement of transfusion, or length of stay. Conclusions: H. pylori positivity was associated with lower short-term mortality in acute NVUGIB, although this finding may reflect baseline clinical differences rather than a direct effect on bleeding severity.

Duodenal ulcer bleeding is a common cause of non-variceal upper gastrointestinal bleeding. Although endoscopic hemostasis is recommended as the first-line treatment, a subset of patients experience failure of endoscopic therapy and require further intervention, for which transcatheter arterial embolization (TAE) has become a commonly used salvage treatment. In clinical practice, however, angiography may fail to demonstrate definite active bleeding, posing challenges for subsequent therapeutic decision-making. Under such circumstances, empiric embolization is frequently performed, yet its clinical outcomes have not been systematically evaluated. This two-center retrospective observational study included 31 patients who underwent TAE for duodenal ulcer bleeding after failed endoscopic hemostasis between January 2017 and November 2024 and showed no definite evidence of active bleeding on angiography. Clinical characteristics, endoscopic findings, interventional procedures, and clinical outcomes were retrospectively reviewed. The primary outcome was initial clinical hemostasis following TAE, while secondary outcomes included early rebleeding, delayed rebleeding, 30-day bleeding-related mortality, 30-day non-bleeding-related mortality, and 90-day all-cause mortality. Among the 31 patients included, initial clinical hemostasis was achieved in 25 (80.6%). Early rebleeding occurred in 1 patient (3.2%), and delayed rebleeding was observed in 5 patients (16.1%). The 30-day bleeding-related and non-bleeding-related mortality rates were 12.9% (4/31) and 6.5% (2/31), respectively, and the 90-day all-cause mortality was 25.8% (8/31). No major embolization-related complications, such as bowel ischemia or pancreatitis, were observed. Subgroup analysis showed that the initial hemostasis rate was significantly higher in the coil-plus-cyanoacrylate group than in the coil-only group (95.0% vs. 54.5%, P = 0.013), while 30-day bleeding-related mortality was numerically lower (5.0% vs. 27.3%, P = 0.115), though this difference did not reach statistical significance. For patients with angiography-negative duodenal ulcer bleeding after failed endoscopic hemostasis, TAE appears to be a feasible and safe salvage option. These preliminary findings suggest that empiric embolization may achieve effective bleeding control even in the absence of definite angiographic evidence of active bleeding. An exploratory subgroup analysis suggested that the choice of embolic material may influence early hemostatic outcomes, warranting further prospective investigation.

Long-term excessive alcohol consumption and unhealthy lifestyles disrupt gastric homeostasis, increasing the risk of gastritis and gastric ulcers. However, conventional synthetic drugs are often limited by poor bioavailability, low antioxidant capacity, and gastrointestinal toxicity. In this study, a sodium alginate-based composite hydrogel loaded with Lactobacillus rhamnosus JM023 postbiotics was successfully developed. The hydrogel exhibited favorable mechanical properties (G' > G''), slow degradation (retaining more than 95% mass after simulated gastrointestinal digestion), and excellent biocompatibility (maximum hemolysis rate of 3.10%). It significantly alleviated gastric bleeding and reduced ulcer area (ulcer proportion: 9.67 ± 3.54%). Mechanistically, the hydrogel exerted antioxidant and anti-inflammatory effects by enhancing SOD, GSH, and CAT activities, downregulating TNF-α, IL-1β, and IL-6, and modulating the Nrf2/HO-1 and NF-κB signaling pathways. It also restored gut microbiota homeostasis by increasing the relative abundance of beneficial genera, including Allobaculum, Lactobacillus, Adlercreutzia, and Oscillospira. Overall, this study presents a novel and effective strategy for alleviating alcohol-induced gastric ulcers using Lactobacillus rhamnosus JM023 postbiotic-loaded composite hydrogels.

Randomised trials have suggested the benefit of potassium-competitive acid blockers (P-CABs) is superior to proton pump inhibitors (PPIs) for ulcer recurrence in high-risk aspirin users. However, real-world comparative effectiveness across diverse antithrombotic regimens remains poorly defined. We evaluated P-CABs versus PPIs for preventing upper gastrointestinal (GI) bleeding in patients with acute atherothrombotic disease and using antithrombotic therapy. This retrospective cohort study utilised hospital-based Common Data Model data (2018-2024). Patients with acute cardiovascular or cerebrovascular disease receiving antithrombotic therapy who initiated a PPI or P-CAB were included. Drug exposure was modelled as a time-varying variable to mitigate immortal-time bias. The primary outcome was upper GI bleeding, analysed via time-dependent Cox regression adjusted for age, sex, comorbidities, and concomitant medications. Among 2255 patients (PPI: 1726; P-CAB: 529) in which 53 upper GI bleeding events occurred during a median follow-up of 637 days. P-CAB use was associated with a significantly lower risk of upper GI bleeding than PPIs (incidence rate 5.7 vs. 25.8 per 1000 person-year; adjusted hazard ratio [HR] 0.22, 95% CI 0.06-0.75, p = 0.016). P-CABs showed a profound reduction in moderate-to-severe upper GI bleeding (HR 0.11, 95% CI 0.02-0.60; p = 0.011). Notably, no bleeding events occurred in P-CAB users with high antithrombotic burden (≥ 2 agents). In patients receiving antithrombotic therapy, P-CABs are associated with a significantly lower risk of clinically significant GI bleeding compared to PPIs. These findings support P-CABs as a potent acid-suppressive strategy for gastroprotection in high-risk populations.

Signs, assessment and care of upper gastrointestinal bleed

To compare five established pre-endoscopic risk scores in acute upper gastrointestinal bleeding (AUGIB) and to derive a hybrid score (Acute Gastrointestinal Bleeding ABC-GBS Triage Evaluation (AGATE)) integrating mortality prediction and triage utility. We conducted a single-centre retrospective cohort study at Kayseri City Hospital, Kayseri, Türkiye, including 5000 consecutive adults with endoscopically confirmed AUGIB (January 2020-January 2025). The primary outcome was 30-day mortality; secondary outcomes were therapeutic intervention and 30-day rebleeding. Age-Blood tests-Comorbidities (ABC), Mental status-ASA class-Pulse-Albumin-Systolic blood pressure-Haemoglobin (MAP(ASH)), Haematemesis-Heart rate-Haemoglobin-Blood pressure-Blood urea nitrogen, Glasgow-Blatchford score (GBS) and Albumin, INR, Mental status, Systolic blood pressure, Age ≥65 were calculated at presentation. AGATE was derived using multivariable logistic regression for the composite end point (mortality or intervention) and internally validated with 1000 bootstrap resamples. Mortality was 9.2% (460/5000), intervention was required in 71.0% (3550/5000) and rebleeding occurred in 14.5% (725/5000). For mortality, ABC (area under the receiver operating characteristic curve (AUROC) 0.83, 95% CI 0.80 to 0.86) and MAP(ASH) (AUROC 0.81, 95% CI 0.78 to 0.84) demonstrated the highest discrimination; for intervention, GBS (AUROC 0.78, 95% CI 0.74 to 0.82) and MAP(ASH) (AUROC 0.77, 95% CI 0.73 to 0.80) demonstrated the highest discrimination. AGATE achieved AUROCs of 0.85 (95% CI 0.82 to 0.87) for mortality and 0.80 (95% CI 0.77 to 0.82) for intervention. For the composite end point, AGATE outperformed GBS (AUROC 0.86, 95% CI 0.83 to 0.88 vs 0.77 95% CI 0.74 to 0.80; p<0.001), with an optimism-corrected AUROC of 0.843. Using a low-risk cut-off (≤5), AGATE classified 38% (1900/5000) as low risk (0.3% mortality, 4.0% intervention), compared with 15% (750/5000) for GBS ≤1. AGATE provides balanced pre-endoscopic triage by integrating predictors from ABC and GBS, expanding the low-risk group while maintaining very low short-term mortality. Prospective external validation in independent multicentre settings is required.

Previous studies have reported seasonal variations in the incidence of acute upper gastrointestinal bleeding especially so for peptic ulcer. There is no study focusing on this issue in our locality. The study aimed to assess whether monthly and seasonal climatic changes during the year have an influence on the incidence of bleeding from duodenal ulcer (DU) and erosive gastroduodenitis (EGD); both of which are major causes of bleeding in this region. This case-series study involved (416) patients presented with acute upper astrointestinal bleeding at Al-Salam General Hospital in Mosul during the period from 1 April 2001 to 31 March 2011. All patients were subjected to endoscopic examination and causes of bleeding, and date of examination were documented. Monthly and seasonal evaluation of bleeding incidents were made and correlated with the major causes of bleeding. The main causes of bleeding were (EGD) and (DU) making 41.11% and 30.53% respectively. Duodenal ulcer bleeding showed significant monthly (p=0.035) and seasonal (p=0.005) fluctuations, peaked in November, during autumn, and the trough was in July and August during summer (P=0.0004). Bleeding due to (EGD) showed neither significant monthly (p=0.117) nor seasonal (p=0.711) variations. In this study (DU) bleeding showed clear seasonal fluctuation which is not detected in bleeding due to (EGD).

Paotianxiong polysaccharides as a stabilizer for protein nanoparticles and construction of an enhanced gastric acid-responsive hydrogel for delivery of fisetin to alleviate alcoholic gastric injury.

Population-based deprescribing strategy for proton pump inhibitors: health outcomes from a case-control study.

Patients with acute upper gastrointestinal hemorrhage (UGIH) often present with airway contamination due to hematemesis and gastric reflux. Conventional endotracheal intubation (ETI) in the supine position faces challenges such as limited visualization and high aspiration risk. While securing the airway and controlling bleeding are both critical during resuscitation, simultaneous achievement of these goals remains technically difficult. A 56-year-old woman with esophageal variceal rupture presented with hemorrhagic shock. After left-lateral positioning and rapid-sequence induction, a cuffed endotracheal tube pre-loaded with a J-tipped guidewire was advanced through the right channel of a bite block into the oropharynx. Under continuous direct visualization provided by a standard diagnostic gastroscope, the tube was steered into the glottis on the first attempt. The scope was then advanced through the tube into the esophagus, permitting immediate endoscopic band ligation of all bleeding varices. The entire process from securing the airway to endoscopic access was completed without apparent delay, with no clinically evident aspiration and with maintained hemodynamic stability. This case demonstrates the technical feasibility of standard gastroscope‑guided intubation in the lateral decubitus position for airway management in massive upper gastrointestinal (GI) bleeding with hypovolemic shock. The procedure enabled rapid airway control without repositioning‑induced hemodynamic instability, allowed seamless transition to endoscopic hemostasis, and was not associated with visible aspiration or mucosal injury. Considering the limitations of a single case, the approach may reduce risk and appears feasible in this instance. These findings are descriptive and not generalizable. The technique may be considered a potential alternative in selected high‑risk "bloody airway" scenarios when advanced bronchoscopic equipment is unavailable. Further validation in larger studies is needed.

Patients on long-term anticoagulation face increased bleeding risk when antiplatelets are co-prescribed, especially upper gastrointestinal (GI) bleeding. Guidelines recommend limiting antiplatelet use to highly select patients on background anticoagulants and promoting GI prophylaxis with proton pump inhibitors (PPIs) for those requiring dual antithrombotic therapy. To assess the impact of an anticoagulation management service (AMS)-led intervention on reducing excess antiplatelet use and increasing PPI prescribing in patients who require continued antiplatelet therapy. This study of retrospective chart review included adults (≥ 18 years) on long-term direct oral anticoagulant (DOAC) therapy from October 2023 to September 2024. The intervention group included AMS-enrolled patients who received structured annual anticoagulation review. The control group consisted of DOAC patients receiving usual care outside AMS. The AMS annual review aims to optimize antithrombotic therapy by deprescribing unnecessary antiplatelets and initiating PPIs when clinically indicated. Of 8,462 eligible patients, 3,125 were in the AMS group and 5,337 in the non-AMS group. Antiplatelet use was significantly lower in AMS patients at baseline (9% vs. 15%) and study end (7% vs. 16%) (p < 0.0001). PPI use was significantly higher in AMS patients at both time points (50% vs. 30% for baseline, 67% vs. 38% at the end of study) (p < 0.0001). Acceptance rates for AMS recommendations were 18.8% for antiplatelet discontinuation and 33% for PPI initiation. AMS-led interventions effectively reduced concurrent antiplatelet use in patients on background DOAC and increased PPI prescribing in those on dual therapy, demonstrating the value of centralized anticoagulation services in primary care.

Risk of complicated upper gastrointestinal bleeding with direct oral anticoagulants: an Asian population-based analysis.

BACKGROUND Portal hypertension (PHT) in children is associated with a high risk of esophageal/gastric varices (EV), which may result in life-threatening upper gastrointestinal bleeding, particularly in those with clinically significant varices (CSV). Upper gastrointestinal endoscopy (UGIE) is reference standard for variceal detection, but is invasive, resource-intensive, and often requires anaesthesia in children. Non-invasive imaging modalities, such as liver and splenic stiffness measurements, show promise but have limited availability and feasibility, particularly in resource-limited settings. Blood-based non-invasive tests represent an attractive alternative; however, their diagnostic performance in children has not been comprehensively synthesised. AIM To systematically evaluate and meta-analyse diagnostic accuracy of blood-based non-invasive tests for predicting EV and CSV in pediatric PHT. METHODS We conducted a systematic review and diagnostic accuracy meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies guidelines. PubMed, EMBASE, and Scopus were searched from inception to October 2025. Studies evaluating aminotransferase-to-platelet ratio index (APRI), platelet count, clinical prediction rule (CPR), varices prediction rule (VPR), or King’s variceal prediction score (K-VaPS) against UGIE in children (≤ 18 years) with PHT were included. Hierarchical summary receiver operating characteristic models were used to pool sensitivity, specificity, diagnostic odds ratios, and area under the curve (AUC). Subgroup, sensitivity, and publication bias analyses were performed. RESULTS Twenty-four studies were included [APRI-17 studies (n = 1355), platelet count-11 studies (n = 1040), CPR-12 studies (n = 944), VPR-7 studies (n = 655), K-VaPS-5 studies (n = 315)]. APRI demonstrated pooled sensitivities and specificities of 0.77 and 0.71 for EV and 0.72 and 0.61 for CSV, with corresponding AUCs of 0.795 and 0.776, respectively. Platelet count showed pooled sensitivities and specificities of 0.69 and 0.77 for EV and 0.66 and 0.72 for CSV, with AUCs of 0.834 and 0.714, respectively. Among prediction scores, VPR showed highest accuracy for CSV prediction (AUC = 0.864), followed by K-VaPS (0.727) and CPR (0.717). Substantial heterogeneity was observed across most of the analyses. Diagnostic accuracy was consistently higher in biliary atresia–exclusive cohorts and Asian populations. The certainty of evidence ranged from moderate to very low. CONCLUSION Blood-based non-invasive tests demonstrate moderate accuracy for predicting varices in pediatric PHT and may serve as adjunctive triage tools; however, standardized pediatric thresholds and prospective validation are urgently needed.