Acute Upper Non-variceal and Lower Gastrointestinal Bleeding

BACKGROUNDAcute gastrointestinal bleeding is an emergency condition that can lead to significant morbidity and mortality. Embolization is considered the preferred therapy in the treatment of lower gastrointestinal bleeding when it is unrealistic to perform the surgery or vasopressin infusion in this population. Treatment of acute lower gastrointestinal (GI) bleeding (any site below the ligament of Treitz) using this technique has not reached a consensus, because of the belief that the risk of intestinal infarction in this condition is extremely high. The purpose of the study is to evaluate the effectiveness and safety of this technique in a retrospective group of patients who underwent embolization for acute lower GI bleeding.AIMTo evaluate the efficacy and safety of super-selective arterial embolization in the management of acute lower GI bleeding.METHODSA series of 31 consecutive patients with angiographically demonstrated small intestinal or colonic bleeding was retrospectively reviewed. The success rate and complication rate of super-selective embolization were recorded.RESULTSFive out of thirty-one patients (16.1%) could not achieve sufficiently selective catheterization to permit embolization. Initial control of bleeding was achieved in 26 patients (100%), and relapsed GI bleeding occurred in 1 of them at 1 wk after the operation. No clinically apparent bowel infarctions were observed in patients undergoing embolization.CONCLUSIONSuper-selective embolization is a safe therapeutic method for acute lower GI bleeding, and it is suitable and effective for many patients suffering this disease. Importantly, careful technique and suitable embolic agent are essential to the successful operation.

Acute gastrointestinal (GI) bleeding is a common cause of hospitalization. There are conflicting results regarding the effectiveness of early endoscopy in patients with upper GI bleeding. The study aimed to determine the benefit of early endoscopy and the epidemiological characteristics of patients presenting to the emergency department with non-variceal acute upper GI bleeding. Patients over 18 years of age who presented to the emergency department with upper GI between 2015 and 2016 and underwent endoscopy were included in the study. The patients were divided into two groups: early endoscopy group (endoscopy within the 24 h) and late endoscopy group (endoscopy after 24 h). Of 104 patients, 57.7% were man, and the mean age was 66.27 ± 17.64 years. Of the patients who underwent endoscopy, 80 (76.9%) were in the early endoscopy group. There was no difference in blood transfusion needs (P = 0.388), re-bleeding (P = 0.137), the need for surgery, and mortality rates with regard to the timing of endoscopy. The results of the receiver-operating characteristics curve analysis revealed patients with a GBS ≥ 9 were taken as high-risk, and a prognosis analysis was performed accordingly. However, in patients undergoing early endoscopy, a difference was detected with respect to the length of hospital stay (P = 0.011) and treatment costs (P = 0.030). In the comparison with the admission time (working/non-working h) and variables, there were no significant differences in the length of hospital stay (P = 0.230), transfusion needs (P = 0.348), re-bleeding frequency (P = 0.905), and treatment costs (P = 0.094). Endoscopy within 24 h in the setting of acute upper non-variceal GI bleeding is associated with an increase in the length of hospital stay and treatment costs, but is not associated with re-bleeding, transfusion needs, need for surgery, and mortality.

The HALT-IT Trial has shown that tranexamic acid does not improve outcome in acute gastrointestinal bleeding and may instead increase the risk of complications . Tranexamic acid (TXA) is an...

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

IntroductionGastrointestinal bleeding results in significant morbidity, cost and mortality. TXA, an antifibrinolytic agent, has been proposed to reduce mortality; however, many studies report conflicting results.MethodsThe aim of the study was to perform the first systematic review and meta-analysis of RCTs to evaluate the efficacy TXA for both upper and lower gastrointestinal bleeding. This was performed per PRISMA guidelines. PubMed, EMBASE, Cochrane and Scopus databases were searched for RCTs. Dichotomous variables were pooled as risk ratios (RR) with 95% confidence intervals (CI) using the MH method with random effects modelling.ResultsFourteen RCTs were identified with 14,338 patients and mean age of 58.4 years. 34.9% (n = 5008) were female and 65.1% (n = 9330) male. There was no significant difference in mortality between TXA and placebo (RR 0.86 95% CI (0.74 to 1.00), P: 0.05). The secondary outcomes, similarly, did not yield significant results. These included rebleeding, need for surgical intervention (RR: 0.75 95% CI (0.53, 1.07)), endoscopic intervention (RR: 0.92 95% CI (0.70, 1.22)), transfusion requirement (RR: 1.01 95% CI (0.94, 10.7)) and length of stay (RR: 0.03 95% CI (− 0.03, 0.08)). There was no increased risk of VTE, RR: 1.29 95% CI (0.53, 3.16). One trial (n = 12,009) reported an increased risk of seizure in the TXA group, RR: 1.73 95% CI (1.03–2.93).ConclusionTXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures. The authors do not recommend the use of TXA in acute gastrointestinal bleeding.

To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital. All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered. Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy. Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Clinical usefulness of 3% hydrogen peroxide in acute upper GI bleeding: a pilot study

DA-9601 extracted from Artemisia asiatica contains a bioactive compound - eupatilin - that can protect against gastric mucosal damage through anti-inflammatory and anti-oxidative properties and is approved for treating acute and chronic gastritis in Korea, but their ability to protect gastrointestinal (GI) bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs) is unclear. We aimed to compare the protective effects of DA-9601 to those of proton pump inhibitors (PPI) and rebamipide against upper and lower GI bleeding in patients with rheumatoid arthritis (RA) undergoing long-term NSAIDs therapy using the Korean Health Insurance Review and Assessment database. In this nationwide retrospective cohort study, we evaluated patients with RA who concurrently received NSAIDs for >3 months with DA-9601, PPI, or rebamipide between January 2015 and December 2017. The index date was the date of NSAIDs initiation, and all patients were followed up until December 2020 to detect upper and lower GI bleeding. In total, 24,258 patients with RA were eligible, and 5468 (22.5%), 4417 (18.2%), and 14,373 (59.3%) received DA-9601, PPI, or rebamipide, respectively, on the index date. During follow-up, upper and lower GI bleeding occurred in 508 (2.1%) and 402 (1.6%) patients with RA, respectively. The incidence rate of upper and lower GI bleeding was 615/100,000 and 485/100,000 person-years, respectively. Among patients with RA receiving DA-9601, PPI, or rebamipide, the frequencies of NSAIDs-induced upper GI bleeding were 0.5%, 0.4%, and 1.2%, respectively. The frequencies of NSAIDs-induced lower GI bleeding were 0.4%, 0.4%, and 0.9%, respectively. The incidence of NSAIDs-induced upper GI bleeding in patients with RA receiving DA-9601, PPI, and rebamipide was 601/100,000, 705/100,000, and 596/100,000 person-years, respectively, while the incidence of NSAIDs-induced lower GI bleeding in the same groups was 449/100,000, 608/100,000, and 465/100,000 person-years, respectively. In the multivariate Cox regression analysis, no significant difference was observed in lower and upper GI bleeding hazards between patients with RA using DA-9601, PPI, and rebamipide. Our results suggest that DA-9601 may exhibit protection against NSAIDs-induced GI bleeding that is comparable to those of PPI and rebamipide in patients with RA.

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospital admission. However, the majority resolve spontaneously and only a minority require inpatient intervention. We aimed to describe the epidemiology and aetiology of acute LGIB admissions in our institution. We also aimed to validate the Oakland Score, which can identify patients at low risk of adverse outcome from LGIB, in our population and determine the proportion who could have safely avoided admission. Using the prospective, validated Otago Clinical Audit database (DIVA), we searched for adult patients admitted to Dunedin Hospital with a primary diagnosis of LGIB between January 2013 and December 2020. We retrieved data to calculate the Oakland Score and details of inpatient treatment from the electronic patient record. We excluded patients admitted electively, admissions related to inflammatory bowel disease, and those with upper gastrointestinal bleeding. We identified 761 patients of which 501 met inclusion criteria (56% male, median age 76 years, 82% NZ European). Overall, 72% were managed with observation or diagnostic endoscopy, 32% received blood products, and 7% required haemostatic intervention to control bleeding. The area under the receiver operating characteristic curve for the Oakland Score was 0.85 (95% CI, 0.81-0.89). A cut-off score of ≤10 predicted a 95% probability of safely avoiding admission. This equates to saving 30 bed-days annually. The majority of patients admitted with LGIB are managed conservatively. The Oakland Score could be used as a stratification tool to safely reduce the admission rate.

To determine types of respiratory complications encountered in critically ill patients with serious acute upper gastrointestinal (GI) bleeding, and to identify associated risk factors. Retrospective chart review. A university hospital medical ICU. We reviewed medical records of 86 patients admitted to the medical ICU over a 2 1/2-yr period of time, for 107 consecutive episodes of serious acute upper GI bleeding. Clinical features of patients who developed respiratory complications of pneumonia, witnessed aspiration of gastric contents, or who required intubation and mechanical ventilation for other reasons were compared with those features of patients without respiratory complications. Respiratory complications occurred during 23 (22%) serious upper GI bleeding episodes (mean transfusion requirement, 7 units of packed RBCs). Twelve patients developed pneumonia and all had evidence of advanced liver disease. Five patients were observed to aspirate gastric contents and six patients require intubation and mechanical ventilation for reasons other than pneumonia or aspiration. Esophageal sites of bleeding (esophagitis, esophageal ulcers and esophageal varices), advanced liver disease, age greater than 70 yrs, and an Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 13 appeared to be risk factors. Mortality rate was increased in patients with respiratory complications: 70% of patients with respiratory complications died, compared with 4% of those patients without such problems (p less than .001). Respiratory complications are common in critically ill medical patients with serious acute upper GI bleeding, and are associated with a poor outcome. Risk factors include advanced liver disease, esophageal site of bleeding, age greater than 70 yrs, and higher APACHE II score.

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.

IntroductionNational guidelines for the management of upper gastrointestinal (GI) bleeding exist and are based on conclusive evidence for effective clinical practice[1]. A mortality rate in acute admissions of 7% was...

Effect of tranexamic acid on the treatment of patients with upper gastrointestinal bleeding

Aspirin use is associated with gastroduodenal mucosal damage and increased risk of upper gastrointestinal (GI) bleeding. Many aspirin users should receive prophylactic treatment since they often have several risk factors for upper GI complications. The best therapeutic approach for reducing GI toxicity in low-dose aspirin users is still ill-defined as only a few studies have focused on this problem. Omeprazole appears to be very effective in reducing both acute gastroduodenal mucosal damage and upper GI bleeding in the high-risk patient taking low-dose aspirin, but data with other anti-ulcer agents are lacking (misoprostol) or inconsistent (ranitidine) at present. The role of Helicobacter pylori is controversial in NSAID users, but there is now wide agreement that H. pylori infection increases mucosal damage and the risk of upper GI bleeding in low-dose aspirin users.