Concept: Upper gastrointestinal bleeding
Upper gastrointestinal (GI) bleeding is one of the most common, high risk emergency disorders in the western world. Almost nothing has been reported on longer term prognosis following upper GI bleeding. The aim of this study was to establish mortality up to three years following hospital admission with upper GI bleeding and its relationship with aetiology, co-morbidities and socio-demographic factors.
INTRODUCTION: We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). OBJECTIVE: To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS). DESIGN: Retrospective cohort study. PATIENTS: Adults with a primary diagnosis of UGIB. MAIN OUTCOME MEASUREMENTS: Primary outcome: inpatient mortality. Secondary outcomes: composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. RESULTS: Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. LIMITATIONS: Retrospective, single-center study. CONCLUSION: The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.
: To implement an online, prospective collection of clinical data and outcome of patients with acute nonvariceal upper gastrointestinal bleeding (UGIB) in Italy (“Prometeo” study).
To test the ability a new Spanish primary care research database (BIFAP) to capture the association between upper gastrointestinal bleeding (UGIB) and NSAIDs and other drugs and compare the results with previous studies.
Patients on antithrombotic therapy (ATT) have the highest risk of ongoing bleeding and mortality. Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a novel hemostatic agent for the treatment of upper gastrointestinal bleeding (UGIB). Initial reports on its use appear promising in terms of initial hemostasis and rebleeding rates. It is unknown whether this also pertains to patients on ATT. The aim of the current study therefore was to evaluate the efficacy of Hemospray in the treatment of UGIB in patients taking ATTs. A total of 16 unselected consecutive patients with UGIB who were treated with Hemospray were analyzed (eight taking ATT for various indications and eight not on ATT). Initial hemostasis was achieved after Hemospray application in 5 /8 patients on ATT (63 %) and in all eight patients not on therapy (P = 0.20). Rebleeding rates were similar in both groups. These preliminary data on the use of Hemospray in the management of UGIB are promising in both patients with and without ATT; however, caution should be exercised for its use in patients on ATT with spurting arterial bleeding.
PURPOSE: To assess the relative efficacy of empiric gastroduodenal artery (GDA) embolization in reducing recurrent hemorrhage compared to image-guided targeted embolization. METHODS: Data were retrospectively collected for consecutive patients who had catheter angiography for major upper gastrointestinal hemorrhage from May 2008 to November 2010 (n = 40). The total number of cases were divided into two main groups according to angiographic findings: those that demonstrated a site of hemorrhage on catheter angiography (group 1, n = 13), and those where the site of hemorrhage was not identified on catheter angiography (group 2, n = 27). Group 2 was then further divided into patients who received empiric embolization (group 2a, n = 20) and those who had no embolization performed after angiography (group 2b, n = 7). RESULTS: The technical and clinical success rates for embolization in groups 1 and 2a were, respectively, 100 vs. 95 %, and 85 vs. 80 %. There was no statistical significance in the recurrent hemorrhage rate, reintervention rate, or 30 day mortality between targeted and empiric embolization groups. There were no complications attributed to embolization within this study cohort. CONCLUSION: Cases of duodenal-related major upper gastrointestinal hemorrhage where no embolization is performed have poor outcome. Empiric embolization of the GDA in patients with major upper gastrointestinal hemorrhage refractory to endoscopic treatment appears to be a safe and effective treatment, with low reintervention rates and good clinical outcome comparable to patients where the site of hemorrhage is localized and embolized with computed tomographic angiography or catheter angiography and embolized.
Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified.
BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important cause of mortality and morbidity worldwide. Little information is available on the clinical management of non-variceal upper gastrointestinal bleeding in Italy in relation to the current organization of the Italian Emergency Health Services into Level-I and Level-II Emergency Departments (ED), the latter being more complex structures with greater resources. METHODS: A retrospective survey on clinical, endoscopic, and survival data was conducted by the regional sections of the 3 main Italian gastroenterological societies, AIGO, SIED and SIGE, recording all consecutive episodes of non-variceal upper gastrointestinal bleeding referred to 7 centres (4 of which were Level-II Emergency Departments) in Rome, Italy, during a one-year period. A total of 624 consecutive patients (64% males, mean age 67.6±16.2years) were included. Thirty-day mortality was 4.6%. Main factors associated with survival at both univariate and multivariate analysis were the presence of full Rockall score <5 and the admission to a Level-II Emergency Departments (p<0.001). Level-I Emergency Departments admitted patients with a full Rockall score ≥5 (p=0.02) more frequently than patients with negative endoscopic findings (p<0.001). CONCLUSIONS: Referral of non-variceal upper gastrointestinal bleeding patients to Emergency Departments with more resources (Level-II) is associated with reduced mortality. Yet, unfortunately, high-risk patients were more often admitted to Level-I Emergency Departments, which suggests the need for a better organization of the emergency referral system.
GOALS:: 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. BACKGROUND:: Recent studies suggest changes in causes and outcomes of UGIB. STUDY:: 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. RESULTS:: 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. CONCLUSION:: 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.
Background and objectives: To evaluate the predictive value of pre-endoscopic risk scores in patients with upper gastrointestinal bleeding (UGI-B).Patients and methods: The medical records of patients evaluated by emergency esophago-gastro-duodenoscopy (E-EGD) for suspected UGI-B outside regular working hours were retrospectively analysed.Results: During the 75 months of the study period 112 E-EGDs met the inclusion criteria. Mean age was 65.5 ± 14.7 years. 38.4 % of patients were female. Endoscopy revealed 41 gastro-duodenal ulcers, 16 Mallory-Weiss, 13 varices, 4 neoplasia. 72 patients received transfusions, 39 had endoscopic interventions. 2 patients were surgically treated, 16 had recurrent bleeding. 16 of the 110 patients died during hospitalisation. The following sensitivities were found for the Blatchford score (cut-off > 1), the clinical Rockall score (cut-off > 0) and the Adamopoulos score (cut-off > 2) in predicting need for clinical intervention (endoscopic or surgical intervention or transfusion): 100/97.7/93 %, recurrent bleeding: 100/100/93.8 %, in-hospital mortality: 100/93.8/93.8 %, respectively.Conclusions: The Blatchford score is a suitable tool in determining the need for clinical intervention and the risk of recurrent bleeding and death in patients with UGI-B. The clinical Rockall score and the Adamopoulos score (the latter had originally been developed to predict active UGI-B at endoscopy and was used with a lower cut-off in our study) are inferior alternatives.