Upper Gastrointestinal Tract Bleeding Research Articles

Bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients: a hospital-based study

BackgroundThe presence of bacteremia as a complication of variceal bleeding in patients with liver cirrhosis had been investigated by many studies. The aim of this study was to assess the bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients. A cross-sectional study was conducted on 99 patients with chronic liver disease divided into three groups: group I included 35 patients presented with first attack of variceal bleeding, group II included 35 patients presented with recurrent attacks of variceal bleeding, and group III included 29 patients with no history of previous variceal bleeding as a control group. Routine laboratory tests were done, upper GI endoscopy, blood culture, and measurement of procalcitonin level in blood.ResultsPatients with recurrent variceal bleeding had statistically (p < 0.05) the highest percentage of positive blood culture followed by patients with first variceal bleeding and the control (60% vs 45.7% vs 24.1%) respectively. In addition to procalcitonin results, patients with recurrent variceal bleeding had statistically the highest values of PCT followed by patients with first variceal bleeding and the control (1.92 vs 0.325 vs 0.22 ng/ml) respectively. Multivariate regression analysis showed that procalcitonin and hemoglobin only was the significant predictors for variceal bleeding. Hemoglobin at cutoff value of ≤ 9.6 and procalcitonin (ng/dl) at cutoff value of > 1.76 is the most specific in predicting bleeding 86.21%, 86.21% (CI 95%) respectively.ConclusionBacteremia and procalcitonin are risk factor for variceal bleeding in cirrhotic patients. Procalcitonin can be used as easily measurable and surrogate biomarker for bacteremia and variceal bleeding.

Re-audit of upper endoscopy in Assiut University Hospital

Background Audit is an attempt to improve the quality of medical care by measuring the performance in relation to desired standards, whereas re-audit demonstrates improvements that have been made. Patients and methods A prospective study was performed through a medical audit of 100 patients at the endoscopy unit of El-Rajhi Hospital University between January and December 2017. Revision of upper endoscopy, including indications, preparations, and complications, was done. Results The mean age was 59 years. The most frequent comorbidities were liver cirrhosis (70%) and diabetes mellitus (25%). All patients were indicated for endoscopy, as the majority (70%) of patients required urgent upper endoscopy secondary to upper gastrointestinal tract bleeding in contrast to the previous study as 4% of patients were not indicated. There was an increase in the percentage of complications in our study owing to the increased percentage of postband ulcers (92%) in comparison with the previous study (90%). Conclusion Improvement in our practice was noticed after recommendations of the previous audit regarding preparation and indications. It is important that a re-audit takes place following the implementation of changes.

The Congenital Absence of the Portal Vein

Congenital absence of the portal vein (CAPV) is a rare defect often accompanied by other abnormalities such as heart defect, skeletal anomalies and / or liver tumors [1]. We describe here a case of CAPV revealed by an upper gastrointestinal tract hemorrhage in a child aged 02 years and 8 months. The esogatro-duodenal fibroscopy revealed the presence of Esophageal varices grade II, abdominal ultrasound revealed a large liver with no visualization of the spleen. Subsequent abdominal computed tomography revealed the presence of a spleno-mesaraic trunk measuring 7 mm in anteroposterior diameter receiving the inferior and superior mesenteric vein and a small splenic vein draining by dilated peri-gastric and peri-esophageal leads. Associated with splenic hypoplasia and portal trunk atresia. The rest of the malformative assessment was negative

Neuropatía óptica asociada con lesión de Dieulafoy

Objetivo: describir el caso de un paciente del Hospital de San José de Bogotá con hemorragia del tracto digestivo superior secundaria a lesión de Dieulafoy, que presentó cuadro compatible con neuropatía óptica anterior isquémica no arterítica (NOIANA). Se hace una revisión narrativa y búsqueda sistemática de la literatura para determinar las características clínicas, demográficas, tratamiento y pronóstico visual de los pacientes con NOIANA. Materiales y métodos: reporte de caso, revisión narrativa y búsqueda sistemática de la literatura en las bases de datos Medline (vía Ovid) y Embase de NOIANA secundaria a hipovolemia. Se analizaron las variables sociodemográficas, clínicas, diagnóstico, condiciones asociadas, tratamiento y pronóstico visual. El análisis estadístico se realizó mediante frecuencias absolutas y relativas. Resultados: la mejoría de agudeza visual final en los pacientes que presentaron un episodio de NOIANA es incierta. En 42% hubo algún tipo de mejoría de la agudeza visual, independiente del tratamiento recibido. Menos del 50% de los casos clínicos reportados incluidos en este estudio que recibieron tratamiento con corticoides intravenosos mejoraron la visión. Discusión: la NOIANA por choque hipovolémico es una entidad infrecuente y poco reportada que puede generar cambios irreversibles en la agudeza visual, por lo que es importante sospecharla y detectarla para dar un manejo oportuno. Este caso de NOIANA es uno de los pocos descritos como secundarios a hemorragia digestiva y el primero asociado con lesión de Dieulafoy.

Left-Sided Portal Hypertension: A Case Series

Left-sided portal hypertension is rarely found, but this condition may cause gastrointestinal tract bleeding and can be life-threatening. The exact incidence of left-sided portal hypertension is unknown as it is rarely found, approximately 1-5%, and most cases were misdiagnosed. We reported 3 cases of left-sided portal hypertension in male patient aged 34 years old, female patient aged 29 years old, and female patient aged 35 years old. Most diagnosis was made based on the clinical findings by excluding the diagnosis of cirrhotic portal hypertension. Splenic vein angiography remains the gold standard in diagnosing left sided portal hypertension. Left-sided portal hypertension is difficult to differentiate from cirrhotic portal hypertension because in these both abnormalities, varices can be present. Left-sided portal hypertension can be considered as a diagnosis in patient with upper gastrointestinal tract bleeding due to oesophageal varices, gastric varices, or portal hypertension gastropathy, accompanied with hypersplenism without the presence of hepatic abnormality or cirrhosis.

Idiopathic Intrahepatic Artery Aneurysm Presenting as Acute Hemorrhagic Cholecystitis

Intrahepatic artery aneurysm or pseudoaneurysm is an unusual condition encountered clinically that accounts for a very small part of all visceral artery aneurysm cases. True incidence of primary or spontaneous intrahepatic artery aneurysm is difficult to be verified and has been rarely reported. For intrahepatic artery aneurysm/pseudoaneurysm, the diagnosis and management are challenging owing to the lower incidence and occult or various presentations. Due to the insidious course, patients with such aneurysms often have a higher risk of rupture, sometimes causing a catastrophic bleeding situation. Herein, we present a case of a 20-year-old woman with idiopathic left intrahepatic artery aneurysm with initial presentation mimicking acute hemorrhagic cholecystitis. Following laparoscopic cholecystectomy, intermittent upper gastrointestinal bleeding occurred. At the second radiologic study, left lateral-superior subsegmental hepatic artery aneurysm was detected. After endovascular treatment, the patient recovered without complications. To avoid delayed diagnosis, we suggest that hepatic artery aneurysm/pseudoaneurysm should always be considered when there is no usual cause of upper gastrointestinal tract bleeding.

Auditing of Nursing care for Patient with Upper Gastrointestinal Tract Bleeding at El -Rajhi Hospital

provided in a given situation. Upper gastrointestinal tract bleeding is the most common emergency and can potentially lead to serious hemodynamic compromise and mortality. Aims of the study: General aim; auditing of nursing care for patient with upper gastrointestinal tract bleeding. Specific aims; To assess current nursing management for patient with upper GIT bleeding .To develop nursing care standers for patient with upper GIT bleeding. And to identify the gap between the current nursing management and nursing care standers for patient with upper GIT bleeding .Subjects and methods: a descriptive research design. Sample: (60) nurses working at the Tropical, `Gastroenterology and Internal medicine department at El-Rajhi hospital, Assuit University . Tool utilized for data collection are assessment of current nursing management for patient with upper gastrointestinal bleeding. Results: the majority of nursing has satisfactory level of knowledge (73%) but above third of nurse's perform the steps of observation checklist correctly Conclusion: Positive correlation between nursing standard and total practice & knowledge score. In addition of a gap between routine nursing care and nursing standard Recommendation Witten standard of nursing care for nurse to monitoring the routine nursing care daily.

Gastrointestinal Bleeding After HeartMate II or HVAD Implantation: Incidence, Location, Etiology, and Effect on Survival.

The number of patients on destination therapy is increasing as long-term survival on continuous-flow left ventricular assist device (CF-LVAD) therapy has improved. Gastrointestinal bleeding (GIB) is a common complication after CF-LVAD implantation, and its risk correlates with longer support time, emphasizing the importance of GIB management. The lower pulsatility of CF-LVADs may promote arteriovenous malformations, which amplify the bleeding risk. Here, we retrospectively analyzed the location, incidence, and survival effect of GIB events in HeartMate II (HM-II) and HeartWare Ventricular Assist Device (HVAD) recipients to provide specific details regarding these complications. From November 2003 to March 2016, 526 patients with chronic heart failure underwent primary implantation of an HM-II (n = 403) or HVAD (n = 123) CF-LVAD at our center. Of the 526 patients, 140 (26.6%) had a GIB event (HM-II: n = 100; HVAD: n = 40), 92 (17.5%) had a single GIB event, and 48 (9.1%) had multiple GIB events (range: 2-9 events). HVAD recipients had a higher incidence of both upper and lower GIB events (p < 0.001 and P = 0.002, respectively) than HM-II recipients. Arteriovenous malformation was the most common etiology for GIB (50 patients/72 events); for this group, the average time-to-event was 300.4 days, the recurrence rate was 34%, and the 90-day and 1-year survival rates were 88.3% and 66.7%, respectively. Age at implantation was the only predictor of GIB. In conclusion, our study provides detailed information about GIB events associated with current CF-LVADs. Additional studies are required to evaluate strategies to reduce the incidence of GIB morbidity.

An Uncommon Hemobilia Resulting from an Congestive Lymph Node Associated with Polypoid Tumor of Gallbladder

Metastatic fibrohistiocytic tumor of the gallbladder is an exceedingly rare entity that may lead to hemobilia or even hypovolemic shock. Its clinical course presents with acute or chronic upper gastrointestinal tract bleeding. Emergency laparoscopic cholecystectomy was performed prior to progression to life-threatening shock. Herein, we report a 47-year-old female presenting with poorly controlled anemia, melena, and fatigue over a half-year period. After surgical and postoperative pathological analysis, she was finally diagnosed as a lymph node hemorrhage associated with intraluminal metastatic fibrohistiocytic tumor of the gallbladder.

Prevention of gastrointestinal bleeding in patients receiving oral anticoagulants: focus on proton pump inhibitors

The review addresses the issue of the gastrointestinal bleeding (GIB) development in patients receiving oral anticoagulants, and the proton pump inhibitors (PPIs) efficiency in reducing of such complications. Epidemiological data on the prevalence of GIB in the presence of nonwarfarin oral anticoagulants (NOACs) and warfarin intake are presented. The factors that increase the risk of bleeding associated with the use of anticoagulants are discussed, including the potential drug-drug interactions and patients’ dietary habits. A description of the scales that assess the bleeding risks during anticoagulant therapy is given. In the second part of the article the principles of prevention and minimization of the GIB risks in the presence of oral anticoagulants treatment are presented. In the context of evidence-based medicine, the PPIs’ role in reducing the risk of GIB is fully discussed. The results of recent large-scale randomized clinical trials and meta-analyses are described in detail, suggesting the benefits of PPIs in the decreasing the risk of the upper gastrointestinal tract bleeding when NOACs and warfarin are prescribed, especially with concomitant therapy with acetylsalicylic acid. So, PPIs can be considered as one of the effective drug prevention “tools” of these complications.

Fluconazole treatment in severe ectopic Cushing syndrome

SummarySevere Cushing syndrome (SCS) is considered an emergency that requires immediate treatment to lower serum cortisol levels. Fluconazole may be considered an alternative treatment in Cushing syndrome when ketoconazole is not tolerated or unavailable. We report a 39-year-old woman with a history of partial pancreaticoduodenectomy due to a periampullary neuroendocrine tumor with locoregional extension. Three years after surgery, she developed liver metastases and was started on 120 mg of lanreotide/month, despite which, liver metastases progressed in the following 6 months. The patient showed extreme fatigue, muscle weakness, delirium, moon face, hirsutism and severe proximal weakness. Laboratory tests showed anemia, hyperglycemia and severe hypokalemia. 24-h urinary free cortisol: 2152 nmol/day (reference range (RR): <276), morning serum cortisol 4883.4 nmol/L (RR: 138–690), ACTH 127.3 pmol/L (RR: 2.2–10). She was diagnosed with ectopic ACTH syndrome (EAS). On admission, she presented with acute upper gastrointestinal tract bleeding and hemodynamic instability. Intravenous fluconazole 400 mg/day was started. After 48 h, her mental state improved and morning cortisol decreased by 25%. The dose was titrated to 600 mg/day which resulted in a 55% decrease in cortisol levels in 1 week, but then had to be decreased to 400 mg/day because transaminase levels increased over 3 times the upper normal level. After 18 days of treatment, hemodynamic stability, lower cortisol levels and better overall clinical status enabled successful bilateral adrenalectomy. This case report shows that intravenous fluconazole effectively decreased cortisol levels in SCS due to EAS.Learning points:Severe Cushing syndrome can be effectively treated with fluconazole to achieve a significant improvement of hypercortisolism prior to bilateral adrenalectomy.Intravenous fluconazole is an alternative treatment when ketoconazole is not tolerated and etomidate is not available.Fluconazole is well tolerated with mild side effects. Hepatotoxicity is usually mild and resolves after drug discontinuation.

Role of Beta Blockers and Band Ligation in upper gastrointestinal tract bleeding.

Objective: To sort out the combine role of beta blockers and band ligation in upper gastrointestinal bleeding&#x0D; Methodology: In this prospective observational study 563 patients were included, (mean age 47 ±6 years, males 69%) with liver cirrhosis and deterioration from Medical ward Mayo hospital Lahore. All the patients had cirrhosis and esophageal varices confirmed by endoscopy. In hospital cirrhotic patients with hypertension and liver cell deteriorations. All the record of betablocker use and band ligation was carefully recorded. Data regarding patient presentation and characteristics were keenly monitored and observe with treatment and improvement as major variables. Mortality was taken as major influential factor. Linear regression model was used.&#x0D; Results: Overall, there were 426 patients getting pharmacological treatment and have band ligation treatment simultaneously. One Hundred and thirty-seven had gastrointestinal bleeding during study time. Standard deviation of patients who had no recurrence of bleeding from last two years was 67±4. Low level of serum albumin, presence of ascites, and treatment with betablockers were the only independent variables that directly influenced the bleeding. The percentage of patients who had only once bleeding during study period was 23±2 percent. The major effects by be ta blockers were preserving after band ligation of source of bleeding.&#x0D; Conclusion: This study demonstrates that best treatment of bleeding in upper gastrointestinal tract is beta blockers, with the use of b and ligation where it is needed. Strict monitoring and guidelines should be under consideration before stop the beta blockers upper gastrointestinal bleeding patients.&#x0D; Keywords: Beta blockers, Band Ligation, Upper Gastrointestinal Tract

Replacement of infected aortoiliac vascular grafts with bifurcated BioIntegral Surgical No-React® bovine pericardial xenografts.

The infection of a vascular prosthesis is potentially fatal, and its effective treatment still remains the greatest challenge for vascular surgeons. We present our initial experience using bovine pericardial vascular prostheses to replace infected aortoiliac vascular grafts. Six consecutive patients with infection of the graft were prospectively included in this study. Infection of the vascular graft was confirmed by clinical symptoms, laboratory tests and the results of computed tomography and positron emission tomography/computed tomography. In all cases, the infected aortoiliac graft was surgically removed and replaced by the bovine-pericardial BioIntegral aortic-bifemoral prosthesis. Technical success was achieved in every case with no in-hospital or 30days mortality. One patient required revision of distal anastomosis due to recurrent bleeding at day four after surgery. One patient presented with upper gastrointestinal tract bleeding during the postoperative period, which was managed endoscopically. The mean hospital stay was 14days (range 9-19). The control CT scan performed 2months after surgery showed significant regression of abscesses and periprosthetic inflammation. Two patients died within 32months of follow-up: one due to heart attack, the other due to generalized sepsis, which was correlated with the previous infection. Four patients are still in follow-up. The BioIntegral prosthesis is patent in all four cases, with no clinical or ultrasonographic signs of infection. Our brief investigation shows that a bovine pericardial prosthesis may be a valuable option in the treatment of vascular grafts infections.

Assessment of the Causes and Outcomes of Upper Gastrointestinal Tract Bleeding Patients in Aswan University Hospital

Background: Gastrointestinal (GI) bleeding is a potentially life threatening abdominal emergency that remains a common cause of hospitalization. Bleeding from the upper gastrointestinal tract is approximately five times more common than from the lower gastrointestinal tract bleeding and seems to be more common in men and the elderly. Aim: Identify various cause and outcomes of upper gastrointestinal tract bleeding patients in Aswan University Hospital by follow-up the patients and their different fates on the numerous lines of treatment. Methodology: This study included 100 patients who were complaining of upper gastrointestinal tract bleeding and selected from patients in Aswan University Hospitals. Results: The results of the current study showed that the most common causes of upper GIT bleeding are the variceal causes representing 57% of causes of GIT bleeding, followed by non-variceal causes representing 43% of causes of GIT bleeding. The most common cause of the variceal bleeding is the esophageal varices alone representing (40%) of the causes of variceal bleeding followed by combined esophageal and gastric varices representing (12%) and the gastric varices alone representing (5%) of the causes of upper GIT bleeding. Conclusion: The endoscopic therapy was successful in most cases. The recurrence rate of bleeding was significantly high among patients with variceal bleeding. The patients with variceal bleeding have fewer treatmentrelated complications and better survival rates when they are treated by band ligation

Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding

Anticoagulant choice and proton pump inhibitor (PPI) cotherapy could affect the risk of upper gastrointestinal tract bleeding, a frequent and potentially serious complication of oral anticoagulant treatment. To compare the incidence of hospitalization for upper gastrointestinal tract bleeding in patients using individual anticoagulants with and without PPI cotherapy, and to determine variation according to underlying gastrointestinal bleeding risk. Retrospective cohort study in Medicare beneficiaries between January 1, 2011, and September 30, 2015. Apixaban, dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy. Hospitalizations for upper gastrointestinal tract bleeding: adjusted incidence and risk difference (RD) per 10 000 person-years of anticoagulant treatment, incidence rate ratios (IRRs). There were 1 643 123 patients with 1 713 183 new episodes of oral anticoagulant treatment included in the cohort (mean [SD] age, 76.4 [2.4] years, 651 427 person-years of follow-up [56.1%] were for women, and the indication was atrial fibrillation for 870 330 person-years [74.9%]). During 754 389 treatment person-years without PPI cotherapy, the adjusted incidence of hospitalization for upper gastrointestinal tract bleeding (n = 7119) was 115 per 10 000 person-years (95% CI, 112-118). The incidence for rivaroxaban (n = 1278) was 144 per 10 000 person-years (95% CI, 136-152), which was significantly greater than the incidence of hospitalizations for apixaban (n = 279; 73 per 10 000 person-years; IRR, 1.97 [95% CI, 1.73-2.25]; RD, 70.9 [95% CI, 59.1-82.7]), dabigatran (n = 629; 120 per 10 000 person-years; IRR, 1.19 [95% CI, 1.08-1.32]; RD, 23.4 [95% CI, 10.6-36.2]), and warfarin (n = 4933; 113 per 10 000 person-years; IRR, 1.27 [95% CI, 1.19-1.35]; RD, 30.4 [95% CI, 20.3-40.6]). The incidence for apixaban was significantly lower than that for dabigatran (IRR, 0.61 [95% CI, 0.52-0.70]; RD, -47.5 [95% CI,-60.6 to -34.3]) and warfarin (IRR, 0.64 [95% CI, 0.57-0.73]; RD, -40.5 [95% CI, -50.0 to -31.0]). When anticoagulant treatment with PPI cotherapy (264 447 person-years; 76 per 10 000 person-years) was compared with treatment without PPI cotherapy, risk of upper gastrointestinal tract bleeding hospitalizations (n = 2245) was lower overall (IRR, 0.66 [95% CI, 0.62-0.69]) and for apixaban (IRR, 0.66 [95% CI, 0.52-0.85]; RD, -24 [95% CI, -38 to -11]), dabigatran (IRR, 0.49 [95% CI, 0.41-0.59]; RD, -61.1 [95% CI, -74.8 to -47.4]), rivaroxaban (IRR, 0.75 [95% CI, 0.68-0.84]; RD, -35.5 [95% CI, -48.6 to -22.4]), and warfarin (IRR, 0.65 [95% CI, 0.62-0.69]; RD, -39.3 [95% CI, -44.5 to -34.2]). Among patients initiating oral anticoagulant treatment, incidence of hospitalization for upper gastrointestinal tract bleeding was the highest in patients prescribed rivaroxaban, and the lowest for patients prescribed apixaban. For each anticoagulant, the incidence of hospitalization for upper gastrointestinal tract bleeding was lower among patients who were receiving PPI cotherapy. These findings may inform assessment of risks and benefits when choosing anticoagulant agents.

Bitlis İlinde Acil Servise Üst Gastrointestinal Kanama İle Başvuran Hastaların Endoskopik ve Demografik Verilerinin Değerlendirilmesi

Giriş ve Amaç: Üst gastrointestinal sistem kanamaları acil servise başvuruların önemli bir nedeni olup, erken tanı ve tedavi gerektirmektedir. Bu çalışmanın amacı Bitlis ilinde üst gastrointestinal sistem kanaması tanısı alan hastaların özelliklerini değerlendirmektir. Gereç ve Yöntem: Ocak 2014-Aralık 2017 tarihleri arasında Bitlis Devlet Hastanesi acil servisi kliniğine üst gastrointestinal sistem kanaması nedeni ile başvuran hastaların verileri retrospektif olarak incelendi. Bu hastaların klinik özellikleri ve kanamaya yol açabilecek etiyolojik nedenler değerlendirildi. Bulgular: Çalışmaya toplam 54 hasta alındı. Hastaların çoğunluğunu erkekler (%59.3) oluşturmaktaydı. En sık başvuru şikayeti hematemezdi. Hastaların %22.8’inde kanamaya predispozan olabilecek ilaç kullanımı mevcuttu. Hastaların ortalama yatış süresi 5.6±3.6 gün idi. Etiyolojik açıdan en sık neden duedonum ve mide ülseri olarak saptandı. Sonuç: Bitlis ilinde üst gastrointestinal sistem kanaması olan hastaların genel özellikleri ülkemizde bu konu ile ilgili yapılan diğer çalışmalar ile uyum göstermekteydi.

Interprofessional collaboration: A gastrointestinal unit case study

Interprofessional collaboration plays a vital role in improving patient outcomes. The ability to work with professionals from different disciplines is considered a critical element of interprofessional practice. In this article, a case of a patient with upper gastrointestinal tract hemorrhage in a gastrointestinal unit is reported and analyzed from the perspective of interprofessional practice. Strategies are also introduced in the article. Enhancing mutual understanding and communication skills is conductive to interprofessional collaboration. Meanwhile, interprofessional education, as another strategy, is proved to improve the quality of health care by enhancing the cooperation among different medical team members.

Relationship between nurse staffing level and adult nursing-sensitive outcomes in tertiary hospitals of Korea: Retrospective observational study

BackgroundNurse staffing level is an important factor on nursing sensitive outcome. The relationships of nurse staffing level with nursing sensitive outcomes such as mortality, upper gastrointestinal bleeding and pressure ulcer have been explored in the United States, Canada, Australia, and New Zealand. Lower level of hospital nurse staffing seems associated with more adverse outcomes, especially mortality. However, there is insufficient evidence of the nurse staffing level-outcome relationship in other indicators. ObjectivesThis study was conducted to describe the status and prove the relationships of nurse staffing level with nursing sensitive outcome indicators for adult medical and surgical inpatients in Korea. Patient and hospital characteristics as covariates on nurse sensitive outcome were also explored. DesignThis was a retrospective observational study. SettingThe study setting was all 46 tertiary hospitals in Korea. ParticipantsWe selected all anonymized patients aged 19 years or older and admitted at tertiary hospitals for two years (2013–2014) using electronic reimbursement claims data. MethodMultiple logistic regression was used to examine relationships of nurse staffing level (accounted for full-time registered nurses in general ward only) with Nursing-sensitive outcomes (NSOs) adjusted for patient and hospital characteristics. NSOs included urinary tract infection, upper gastrointestinal tract bleeding, deep vein thrombosis, hospital-acquired pneumonia, pressure ulcer, sepsis, shock/cardiac arrest, CNS complication, in-hospital death, wound infection, physiologic/metabolic derangement and pulmonary failure. ResultsThe total number of patients in 46 tertiary hospitals in Korea for two years was 3,665,307. Among these, number of patients who had at least one nursing-sensitive outcome was 338,369 (9.23%). The significant relationships of nurse staffing level with six nursing-sensitive outcome rates (urinary tract infection, upper gastrointestinal tract bleeding, hospital-acquired pneumonia, shock/cardiac arrest, in-hospital death, and wound infection) were shown. These six nursing-sensitive outcomes showed an increasing trend as nurse staffing level degraded even after adjusting for patient and hospital characteristics. When the nursing-sensitive outcomes between those of group 1 (bed-to-nurse ratio < 2:1) and group 3 (between 2.5:1 and 3:1) were compared, the adjusted incidence rate of shock/cardiac arrest showed the highest difference (1.06%). ConclusionWe demonstrated strong evidence for the relationships of nurse staffing level with six nursing-sensitive outcomes. We can use this study to improve nursing quality and to inform patients of the nursing quality of hospitals so they can choose hospitals with better nursing quality. The nurse staffing level should be optimized for better outcomes.

Recurrent Hematemesis in a Patient With Aorto-enteric Fistula

We report a case of an aorto-enteric fistula (AEF) in a patient with history of celiac artery aneurysm and graft repair. AEFs are a communication between the aorta and the adjacent gastrointestinal tract. AEFs are a rare, but life-threatening cause of upper gastrointestinal tract bleeding and should be on the differential in patients with history of abdominal vascular surgery. A 32-year-old woman underwent celiac artery aneurysm resection with aorto-common hepatic artery graft interposition. This was complicated by pancreatic head, common bile duct, and portal vein necrosis requiring Whipple pancreaticoduodenostomy, Roux-en-Y hepaticojejunostomy, and portal vein resection with graft interposition. She also developed a pancreatico-cutaneous fistula, eventually closed by EUS-guided pancreatic pseudocyst gastrostomy. The patient was later reassessed with EGD, which showed a gastro-jejunal (GJ) junction Forrest class III ulcer. The patient presented to our institution with hematemesis, melena, and hemoglobin of 4.2 g/dL. EGD showed the known GJ ulcer with new friability and was treated with epinephrine and argon plasma coagulation. However, the patient returned with hematemesis and repeat EGD showed the GJ ulcer had an adherent clot with a visible vessel which was clipped. Abdominal CT angiography (CTA) did not reveal evidence of acute hemorrhage. The patient returned with GI bleeding and repeat abdominal CTA showed a tubular structure concerning for AEF, with possible erosion of the celiac stump into the jejunal blind limb. Vascular surgery was consulted for endovascular graft of the AEF. AEFs can be spontaneous or secondary to a previous aortic surgery. Aortic pseudoaneurysms and/or grafts can cause fistula through aortic pulsation into the intestinal tract and present with GI bleeding. EGD, CT with contrast, and CTA are the most common imaging modalities that aid in diagnosis. EGD can be useful if a graft or pulsatile mass is visualized, but most AEFs occur in the distal duodenum and may not be seen on EGD. CT with contrast is relatively sensitive for signs of AEF such as loss of peri-aortic fat pad, gas around the graft, fluid or soft tissue collection around the aorta, and IV contrast extravasation into the bowel or around the aorta. As in our case, CTA can be helpful in patients with altered anatomy. In addition to CT findings typical for AEF, CTA has greater spatial resolution allowing better visualization of the aortic contour and side branches.Figure: Gas shadow and inflammation surrounding aorta at the level of celiac stump, likely indicative of anastomotic connection to walled off necrosis, which is adjacent to the jejunum.

Randomized pragmatic trial of nasogastric tube placement in patients with upper gastrointestinal tract bleeding

The value of nasogastric (NG) tube placement in patients with upper gastrointestinal tract bleeding (UGIB) is unclear. We therefore aimed to determine the usefulness of NG tube placement in patients...