Upper Gastrointestinal Tract Bleeding Research Articles

Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate

A bloody nasogastric aspirate is believed to imply active upper gastrointestinal tract bleeding, while a nonbloody yellow-green nasogastric aspirate that contains duodenal secretions suggests the absence of bleeding proximal to the ligament of Treitz. To validate these beliefs, physicians were asked to predict the presence of active gastrointestinal tract bleeding and whether bile was present in a nasogastric aspirate obtained immediately before endoscopy in 73 episodes of bleeding in 62 patients. A relationship was found between the physician's assessment of the presence of active bleeding demonstrated endoscopically and the appearance of the nasogastric aspirate. However, the sensitivity and specificity were low (79% and 55%, respectively). No association between the assessment of bile in the nasogastric aspirate and the presence of bile acids was demonstrated. These data do not support the placement of a nasogastric tube to determine whether or not a patient is bleeding, the location of the bleeding, and whether endoscopy should be performed.

Gastrointestinal Tract Hemorrhage

• A bloody nasogastric aspirate is believed to imply active upper gastrointestinal tract bleeding, while a nonbloody yellowgreen nasogastric aspirate that contains duodenal secretions suggests the absence of bleeding proximal to the ligament of Treitz. To validate these beliefs, physicians were asked to predict the presence of active gastrointestinal tract bleeding and whether bile was present in a nasogastric aspirate obtained immediately before endoscopy in 73 episodes of bleeding in 62 patients. A relationship was found between the physician's assessment of the presence of active bleeding demonstrated endoscopically and the appearance of the nasogastric aspirate. However, the sensitivity and specificity were low (79% and 55%, respectively). No association between the assessment of bile in the nasogastric aspirate and the presence of bile acids was demonstrated. These data do not support the placement of a nasogastric tube to determine whether or not a patient is bleeding, the location of the bleeding, and whether endoscopy should be performed. (<i>Arch Intern Med.</i>1990;150:1381-1384)

Absolute bioavailability of pirenzepine in intensive care patients

The absolute bioavailability (f) of pirenzepine was determined in 27 intensive care patients receiving the drug for prophylaxis and therapy of upper gastrointestinal tract bleeding. A multiple oral and intravenous dosage regimen and the times of blood sampling were adapted to individual conditions and treatment. Mean f in the patients was 0.28, which was significantly higher than in 12 normal subjects (0.14). It showed no dependence on age (range 20-82 y), nor on the risk factors cardiac insufficiency, renal and hepatic dysfunction, gastrectomy (Billroth II) and bleeding gastrointestinal ulcers, nor on concomitant administration of metoclopramide or antacids. Due to the wide therapeutic index of pirenzepine, it is concluded that individualization of therapy is not necessary for patients in intensive care.

The Dieulafoy Gastric Erosion

Definitive treatment of the Dieulafoy erosion--once recognized--has generally been surgery. Numerous surgical approaches have been suggested, including: simple oversewing of the lesion, wedge restriction, and gastrectomy with and without vagotomy and pyloroplasty. Attempts at endoscopic electrocoagulation and angiographic embolization have generally been disappointing; however, Pointer et al have recently reported satisfactory control of hemorrhage from Dieulafoy lesions with bipolar electrocoagulation and endoscopic injection sclerotherapy, either independently or in combination. These case reports describe two elderly patients with massive upper gastrointestinal tract bleeding from Dieulafoy's gastric erosion; it is hoped the geriatrician will be alerted to an often unrecognized source of hemorrhage.

Editorial

A number of techniques have been developed to control active upper gastrointestinal tract bleeding. These include thermal devices such as the laser, heater probe, and bipolar circumactive probe (BICAP). Although these devices have proved effective, they vary in cost and at times are cumbersome to use. A simple, inexpensive, readily available means of treating active bleeding from the gastrointestinal tract is injection of the lesion with a sclerosing substance. This method has proved helpful in stopping variceal hemorrhage, and the simplicity of the equipment and procedure makes it an outstanding candidate therapy for treating other causes of hemorrhage. Although the method is not well known in the United States, it has been applied in Japan and Europe. Most studies so far have been uncontrolled, but in over 700 patients reported in the world literature, effective initial hemostasis has been achieved in about 90% of patients overall. Success rates have been somewhat dependent on the site and rate of bleeding. No deaths have been reported from the procedure. We review the current status, techniques, and types of sclerosing agents and provide a detailed analysis of results of injection sclerotherapy. We propose that although the technique is simple, the effectiveness and routine application to the patient with upper gastrointestinal hemorrhage await careful controlled studies and comparison with other available hemostatic methods.

Cyanide and arsenic poisoning by intravenous injection

A 29-year-old man was found unresponsive a few minutes after self-injecting undetermined amounts of potassium cyanide and sodium arsenite intravenously in a suicide attempt. Treatment with the Lilly Cyanide Antidote kit rapidly resolved the initial coma, despite a whole blood cyanide level of 4.4 micrograms/mL. A 12-hour urine arsenic collection begun on admission showed 10,065 micrograms arsenic/12 hr. The patient received intramuscular BAL initially, which was followed by two ten-day courses of oral D-penicillamine. Complications included upper gastrointestinal tract bleeding requiring transfusion, transient elevations of liver function tests, self-limited complaints of decreased vision with conjunctival hyperemia and photophobia, and an abscess at the injection site. Although specific antidote therapy completely resolved the cyanide toxicity, early and prolonged arsenic chelation did not prevent a mild sensory peripheral neuropathy from developing with onset about 17 days after self-injection.

Upper Gastrointestinal Bleeding During the Holy Month of Ramadan

Letters to the EditorUpper Gastrointestinal Bleeding During the Holy Month of Ramadan Ala U. ToukanFRCP(C), FACP Ala U. Toukan Gastroenterology Unit, Jordan University Hospital Amman, Jordan Search for more papers by this author Published Online::1 Jan 1989https://doi.org/10.5144/0256-4947.1989.93SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor. The holy month of Ramadan is a month of fasting for Muslims. Patients with upper gastrointestinal (UGI) lesions are often exempted from fasting by prescription of their physicians on the basis that symptoms might worsen or complications may occur. Upper gastrointestinal tract bleeding is a complication often said to occur as a consequence of the action of unbuffered gastric acid on UGI lesions, in particular duodenal ulceration, thus leading to an increased prevalence of UGI bleeding during Ramadan. However, these claims have not been supported by convincing analysis.We have reviewed episodes of massive UGI bleeding presenting to Jordan University Hospital during Ramadan for a 10-year period (1978-1987), and compared these to an equivalent nonfasting period. Massive UGI bleeding was defined as loss of 1000 mL or more of blood, estimated by a blood pressure of < 100/60 mm Hg or a postural decrease in BP of > 20/10 mm Hg, and/or a drop in hemoglobin level of a minimum of 10%, in the presence of hematemesis, blood per nasogastric tube, or melena at presentation. Cause of bleeding was diagnosed by endoscopy performed within 24 hours of admission. Chi-square test was used to assess differences between the number of bleeding episodes in the fasting and nonfasting periods.Bleeding episodes during Ramadan months over the 10-year study period were aggregated and compared to the number of episodes presenting during an equivalent period of nonfasting Months. We have noted previously that all UGI bleeding episodes, including those caused by duodenal ulcer, present less frequently in the months of April and September, than October to March (unpublished data). Ramadan is the ninth month of the Hejira (lunar) year, which is approximately 12 days shorter than the Gregorian year. During the 10-year period of this study, Ramadan has always fallen between the months of April to September, and we included the aggregate of the mean number of bleeding episodes counted for each of these months (with the exception of the Ramadan months) over the 10-year study period as the nonfasting control period in our analysis. This analysis was carried out for each of the total number of bleeding episodes as well as those due to duodenal ulcer.There were slightly more bleeding episodes in the nonfasting months than the fasting months of Ramadan over the 10-year study period in respect to both the total number of episodes and those in whom duodenal ulcer was the source of bleeding (Figure 1). This difference, however, did not reach statistical significance. Thus, it would appear that there is no increased frequency of UGI bleeding episodes during the fasting month of Ramadan.Figure 1. Number of bleeding episodes during Ramadan compared to the nonfasting control period, by total number of bleeds and those from duodenal ulcer (DU).Download Figure Previous article Next article FiguresReferencesRelatedDetails Volume 9, Issue 1January 1989 Metrics History Published online1 January 1989 InformationCopyright © 1989, Annals of Saudi MedicinePDF download

Treatment of Campylobacter pylori-associated antral gastritis in children with bismuth subsalicylate and ampicillin

We evaluated the efficacy of medical therapy, consisting of liquid bismuth subsalicylate prescribed either in combination with oral ampicillin (n = 15) or alone (n = 1), in the clearing of bacterial colonization on the antrum in 16 children with Campylobacter pylori-associated antral gastritis. We also examined the effects of medical treatment on altering the severity of associated antral inflammation. Eight patients had upper gastrointestinal tract hemorrhage, two had acute gastric outlet obstruction, and 10 had symptoms of episodic epigastric abdominal pain. Duodenal ulcers were demonstrated in 10 of the 16 patients; in the other six, C. pylori-associated antral gastritis was documented without evidence of acute peptic ulceration. Seven days after a 6-week course of medical therapy, repeat upper endoscopy plus mucosal biopsy specimens showed that C. pylori colonization of the antrum had cleared in 12 of the 16 (75%) patients. Inflammation in the antrum improved in all patients in whom colonization by C. pylori was eradicated. In contrast, in the four with persistent colonization of the antrum, the severity of antral gastritis had not improved (p less than 0.01). Clinical symptoms improved in 9 of 12 patients in whom C. pylori colonization was no longer present, whereas subjective symptoms were unaffected in those with continued bacterial colonization of the antrum (p less than 0.05). We conclude that oral bismuth subsalicylate, in conjunction with ampicillin, can eradicate C. pylori colonization of the antrum, and that clearing of C. pylori is correlated with an improvement in the associated antral gastritis and clinical symptoms. These findings provide additional support for the hypothesis that these gastric organisms could play an etiologic role in primary antral gastritis and peptic ulcer disease.

Prophylaxis of Upper Gastrointestinal Tract Bleeding in Mechanically Ventilated Patients

Sixty-two mechanically ventilated patients were randomized into three study groups to compare the efficacy of sucralfate vs cimetidine and antacid regimens for the prevention of upper gastrointestinal tract bleeding. Only five study patients (8%) developed bright-red blood per nasogastric tube; four patients received the antacid regimen and one received cimetidine. None of the patients receiving sucralfate developed acute upper gastrointestinal tract bleeding. Bleeding was not severe enough in any patient to require endoscopy or surgery. There were no significant differences in the three groups when several major risk factors for gastrointestinal tract bleeding were analyzed, including sepsis, hypotension, steroid use, adult respiratory distress syndrome, gastric pH of 4 or less, previous peptic ulcer disease, peritonitis, and jaundice. A significantly higher incidence of acute renal failure was noted in the antacid-treated group when compared with the cimetidine and sucralfate groups. We find preliminary evidence that sucralfate is as efficacious as and more cost-effective than either cimetidine or antacids for prophylaxis of stress-related gastrointestinal tract bleeding in the critically ill ventilator-dependent patient.

Prophylaxis of upper gastrointestinal tract bleeding in mechanically ventilated patients. A randomized study comparing the efficacy of sucralfate, cimetidine, and antacids

Prophylaxis of upper gastrointestinal tract bleeding in mechanically ventilated patients. A randomized study comparing the efficacy of sucralfate, cimetidine, and antacids

Propranolol in the Prevention of First Upper Gastrointestinal Tract Hemorrhage in Patients with Cirrhosis of the Liver and Esophageal Varices

We conducted a prospective, randomized, multicenter, single-blind trial of propranolol as compared with placebo in the prevention of first upper gastrointestinal tract bleeding in patients with cirrhosis of the liver. A total of 230 patients (90 percent with alcoholism and 46 percent with a Child-Pugh grade C classification) with large esophageal varices without previous bleeding were randomly assigned to receive either propranolol (n = 118) or placebo (n = 112), after they had been divided into two groups according to the severity of their liver disease. The end points of the study were bleeding and death. The dose of propranolol was progressively increased to decrease the heart rate by 20 to 25 percent. The final doses were 40 mg of conventional propranolol and 160 and 320 mg of long-acting propranolol daily in 22 percent, 60 percent, and 18 percent of patients, respectively. The mean (+/- SD) follow-up time among survivors without bleeding was 436 +/- 172 days. The cumulative percentages of patients free of bleeding two years after inclusion in the study were 74 percent (95 percent confidence limits, 61 and 83) in the propranolol group and 39 percent (95 percent confidence limits, 15 and 69) in the placebo group (P less than 0.05). Cumulative two-year survival was 72 percent (95 percent confidence limits, 60 and 81) in the propranolol group and 51 percent (95 percent confidence limits, 37 and 64) in the placebo group (P less than 0.05). The advantage of propranolol over placebo was maintained when potentially confounding variables were adjusted with use of the Cox model. Side effects occurred in 17 percent of the patients who received propranolol and led to the stopping of treatment in 11 percent. We conclude that propranolol can decrease the incidence of first bleeding and death during a period of two years in patients with cirrhosis and large varices.

Endoscopic diagnosis of upper gastrointestinal tract bleeding from a duodenal diverticulum

The clinical significance of duodenal diverticula has been a matter of controversy for many years. Although most diverticula are innocuous, over the last two decades various studies have established an association with biliary tract and pancreatic disease. I 4 Also, multiple reports have appeared describing life-threatening situations related to duodenal diverticula, e.g., perforation, cholecystitis, intestinal obstruction, and massive hemorrhage.5-8 Bleeding from a duodenal diverticulum can be caused by erosion into a vessel such as the aorta or a mesenteric vessel, by bleeding ectopic gastric mucosa, or from a local inflammatory process.12 A rare case of bleeding from an intradiverticular polyp has also been documented. This potentially lethal complication is usually diagnosed only at laparotomy. We report a case in which the diagnosis of upper gastrointestinal tract bleeding from a duodenal diverticulum was made preoperatively with endoscopy. Considerations regarding management and surgical approach are discussed.

Influence of non-steroidal anti-inflammatory drugs on the outcome of faecal occult blood tests in screening for colorectal cancer.

Non-steroidal anti-inflammatory drugs have been accused of causing false positive results in faecal occult blood tests for colorectal cancer. A study was therefore performed in 10,931 people undergoing faecal occult blood screening tests to assess the effect of these drugs on the predictive value of a positive test result. Those with a positive result were interviewed and a full drug history was taken before they underwent a full colorectal examination. Of the 455 people with a positive result, 50 were taking non-steroidal anti-inflammatory drugs: 10 (20%) had colonic neoplasia. Of the 405 who were not taking non-steroidal anti-inflammatory drugs, 129 (32%) had colonic neoplasia. These detection rates were not significantly different, and the predictive value of a positive result for an adenoma larger than 1 cm was 14% in the group not taking anti-inflammatory drugs and 26% in the group taking them (not significant). These results suggest that a finding of occult faecal blood cannot be attributed to upper gastrointestinal tract bleeding caused by non-steroidal anti-inflammatory drugs and should be followed by a thorough colorectal examination.

The Relative Gastrointestinal Toxicity of the Nonsteroidal Anti-inflammatory Drugs

To assess the relative rate or upper gastrointestinal (UGI) tract bleeding associated with nonsteroidal anti-inflammatory drugs (NSAIDs), we performed a retrospective cohort study using 1980 billing data from all Medicaid patients in the states of Michigan and Minnesota. The rate of UGI tract bleeding in the 30 days following each drug exposure was examined in the 88,044 patients dispensed only one of seven NSAIDs. The rate of UGI tract bleeding differed significantly among users of these drugs. Stratification and logistic regression were used to adjust for multiple potential confounding factors, without substantive changes in the results. An alcohol-drug interaction was found. Sulindac users had the highest rate of UGI tract bleeding, and it was the only drug statistically different from ibuprofen. When the average daily dose of sulindac received was divided by the maximum recommended daily dose, it was notably higher than those for other drugs. Repeated analyses using data from 1982 confirmed these results. We conclude that there are significant and consistent differences in the incidence of UGI tract bleeding associated with the use of NSAIDs in this population.

Bleeding gastroduodenal ulcers: choice of operations.

AbstractManagement of upper gastrointestinal tract hemorrhage continues to present a challenge in surgical judgment. Endoscopy is the mainstay to precise diagnosis and, although some authorities feel that this modality has not reduced overall mortality, it has, however, played an important role in overall patient management. A bleeding patient may be classified into 1 of 3 separate categories and the algorithms outlined in this article are useful in selecting patients for nonoperative and operative treatment. For the good‐risk patient with a massively bleeding duodenal ulcer (DU) who is hemodynamically stable, truncal vagotomy‐antrectomy, Billroth I reconstruction is our procedure of choice if the inflammatory process in the duodenum is conducive to a safe resection. Our operative method is described along with variations in technique which are used when conventional end‐to‐end gastroduodenostomy is not feasible. Closure of the duodenal stump and Roux‐en‐Y reconstruction or placement of a Roux limb on a severely diseased duodenum following resection is employed in highly selected cases. The Billroth II type of reconstruction is rarely used today in our experience. Truncal vagotomy and pyloroplasty (TV‐P) is reserved for the high‐risk patient who is bleeding massively. An increasing number of these patients are currently encountered as transfers from our intensive care units with associated multiple organ disease and organ failures. Proximal gastric vagotomy with ulcer undersewing has limited application, in our judgment, when faced with the massively bleeding patient. Gastric resection with or without vagotomy along with ulcer excision is our choice for the massively bleeding gastric ulcer (GU) located in the distal 50–60% area of the stomach. For the high‐risk patient with GU, ulcer excision followed by TV‐P is indicated. For the rarely encountered giant GU, gastric resection may be the only option even though the patient is high risk.The choice of the proper operative procedure for the individual patient with massive gastric or duodenal hemorrhage should rest on the experience and the judgment of the surgeon.

Upper gastrointestinal tract bleeding from oral potassium chloride. Comparative risk from microencapsulated vs wax-matrix formulations

Upper gastrointestinal tract bleeding from oral potassium chloride. Comparative risk from microencapsulated vs wax-matrix formulations

Upper Gastrointestinal Tract Bleeding From Oral Potassium Chloride

A retrospective cohort study was performed to assess the relative risk of upper gastrointestinal (UGI) tract bleeding from two formulations of potassium chloride. Relevant information was obtained from 1980 through 1984 Medicaid billing data from the states of Michigan, Minnesota, Florida, and Ohio. After patients with a history of UGI tract bleeding prior to their first prescription for either of the two potassium chloride preparations under study were excluded, data were analyzed for 28,790 patients (143,512 patient-months) dispensed a microencapsulated formulation exclusively and 76,118 patients (560,341 patient-months) dispensed a wax-matrix formulation exclusively. The risk of UGI tract bleeding within 30 days after each prescription for the drug of interest was examined. After sampling from the undiseased study subjects and adjusting for multiple potential confounding variables using logistic regression, an odds ratio (95% confidence interval) of 0.67 (0.52 to 0.85) was observed.

Antiinflammatory drugs and gastric mucosal damage

N ONSTEROIDAL antiinflammatory drugs (NSAIDs) are among the most often used medications in the United States and throughout the world. Fifteen to 20 billion aspirin tablets are consumed each year in the United States.’ Prescriptions for nonsalicylate NSAIDs represented over 4% of the total prescription market in 1983, with consumers spending over a billion dollars for these medications.’ Approximately 3% of the United States population requires treatment for a rheumatic disorder, and NSAIDs are prescribed in most types of noninfectious arthritis.3,4 NSAIDs may cause gastrointestinal (GI) symptoms, erosions and/or ulcers, and upper GI tract bleeding. Therefore, gastric mucosal damage resulting from NSAID use is potentially a major health problem. Corticosteroids are used in a wide variety of medical conditions, including rheumatoid arthritis (RA), bronchial asthma, allergic disorders, and dermatologic diseases. The relationship of corticosteroids to gastric mucosal damage is controversial. Corticosteroids may increase the incidence of peptic ulcer disease and GI hemorrhage’ and potentiate gastric mucosal injury when used in combination with NSAIDs such as aspirin.6*7 This review is divided into two sections. The first part surveys data regarding NSAID induced gastric mucosal injury, and the second portion discusses the role of corticosteroids in causing gastric mucosal damage.

Splenectomy for Thrombocytopenia in Chronic Liver Disease-Reply

Dr Crosby states that immune thrombocytopenia without purpura is not in itself an indication for splenectomy. In general we agree. Splenectomy may be indicated for immune thrombocytopenia with purpura or for other reasons. In our article, two of six patients with chronic liver disease and persistent unexplained thrombocytopenia underwent splenectomy. Patient 1 had splenectomy not for thrombocytopenia per se, but as part of a diagnostic exploratory laparotomy for fever, sweats, and retroperitoneal lymphadenopathy. Patient 3 had upper gastrointestinal tract bleeding associated with moderately severe thrombocytopenia unresponsive to intense medical therapy. Laparotomy was performed to identify and control bleeding, and splenectomy was done because the thrombocytopenia was thought to be contributing to the ongoing bleeding. The bleeding site could not be identified; bleeding stopped after splenectomy and was associated with a rising platelet count. These observations indicate that in some patients with chronic liver disease-related thrombocytopenia, a minimally enlarged spleen may

Famotidine: postmarketing clinical experience.

A postmarketing survey of famotidine usage (phase IV survey) tracked 6346 patients at 602 locations from August 1985 to April 1986. Through the survey, the efficacy and the safety of famotidine were studied. The patients included 4618 cases of peptic ulcer, 106 cases of reflux esophagitis, 1006 cases of upper gastrointestinal tract bleeding, 343 cases of bleeding and ulcer prophylaxis, and 273 cases of gastritis and other diseases, totalling 6346 patients. Efficacy was analyzed by type of disease in terms of overall improvement; results of intermittent hemostatic efficacy were obtained for upper gastrointestinal tract bleeding; and safety was assessed. Overall, the results were good; the 8-week healing rate was 92.4%, and 72.3% of patients had their bleeding controlled within 7 days of beginning famotidine therapy. Side effects occurred in only 0.43% of patients, and abnormalities in laboratory test results were observed in less than 1% of patients. Gastrointestinal side effects, especially constipation, occurred most frequently. Most side effects were mild. The results of this postmarketing survey indicate that famotidine is a safe and effective H2-receptor antagonist.