Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: results of a French prospective multicenter study.

BACKGROUND AND STUDY AIMS: The mortality rate from upper gastrointestinal bleeding (UGIB) remains high, at 5 % - 10 %. The aim of the current study was to describe the epidemiological characteristics, prognostic factors, and actual practice in a cohort of patients with UGIB admitted to French general hospitals. METHODS: From March 2005 to February 2006, a prospective multicenter study was conducted at 53 French hospitals. A total of 3298 patients admitted for UGIB were enrolled consecutively. Patient data were collected up to the date of discharge from hospital. RESULTS: Data were available for 2130 men and 1073 women (mean age 63 ± 18 years), one-third of whom were taking drugs that would increase the risk of UGIB. The two main causes of bleeding were peptic ulcers (38 %) and esophagogastric varices (EGV) or portal hypertensive gastropathy (24.5 %). Mean Rockall score was 5.0 ± 2.3. Endoscopy was performed on 96 % of patients (within 24 hours in 79 %), and 66 % of those with ulcers and 62.5 % of the EGV patients underwent hemostatic therapy when indicated. Rebleeding occurred in 9.9 % of the patients, and 8.3 % died. Independent predictors of rebleeding were: need for transfusion (odds ratio [OR] 19.1; 95 % confidence interval [95 %CI] 10.1 - 35.9); hemoglobin < 10 g/dL (OR: 1.7; 95 %CI 1.1 - 3.3); Rockall score (OR: 1.4 for each 1 point score increase; 95 %CI 1.0 - 1.9), systolic blood pressure < 100 mmHg (OR: 1.9; 95 %CI 1.4 - 2.5), and signs of recent bleeding (OR: 2.4; 95 %CI 1.7 - 3.5). Independent predictors of mortality were: Rockall score (OR: 2.8; 95 %CI 2.0 - 4.0), co-morbidities (OR: 3.6 for each additional co-morbidity; 95 %CI 2.0 - 6.3), and systolic blood pressure < 100 mmHg (OR: 2.1; 95 %CI 1.8 - 2.8). Rockall score, blood pressure and co-morbidities were taken as continuous variables meaning that the OR was 1.4 for every point increase, it was the same for blood pressure. CONCLUSION: UGIB still occurs mainly as a result of peptic ulcers and portal hypertension in France, and causes significant rates of mortality. There is scope for improvement via better prevention (better use of UGIB-facilitating drugs), endoscopic therapy, and management of co-morbidities.

Comparison of two sucralfate dosages presented in tablet form in duodenal ulcer healing.

Two hundred twenty-two patients with endoscopically proven duodenal ulcers participated in a controlled trial to assess and compare the effects of two dosage regimens of sucralfate tablets on ulcer healing, i.e., 1 g four times daily (group A, n = 131) and 2 g twice daily (group B, n = 128). Healing was defined as complete re-epithelialization. Clinical and endoscopic assessments were performed after four weeks (Day 28) and, if complete healing was not achieved, after four more weeks (Day 56). After four weeks, in group A (n = 114: eight patients were lost and nine were withdrawn), the ulcers had healed in 90 patients (79 percent), and in group B (n = 108: six patients were lost and 14 were withdrawn), the ulcers had healed in 80 patients (74 percent). The cumulative healing rates after eight weeks were 94 percent in group A and 95 percent in group B. No serious adverse effect was observed in either group. These results suggest that sucralfate tablets in a dosage of 2 g twice daily are as effective as 1 g four times daily in the treatment of acute duodenal ulcers and could lead to better patient compliance.

[Hepatic involvement associated with ingestion of metapramine]. / Atteinte hépatique associée à la prise de métapramine.

The authors report the cases of 3 women who developed hepatic injury during administration of metapramine, a tricyclic antidepressant introduced in France in 1984. One patient had jaundice and pruritus; the 2 others had loss of weight. Serum alkaline phosphatase and serum transaminase activities were increased in 3 and 2 patients, respectively. Blood hypereosinophilia was found in one patient; erythrocyte sedimentation rate was elevated in 2 patients. The outcome was favorable after drug withdrawal in the 3 patients. Liver biopsy showed centrolobular cholestasis in the 3 patients. There was no rechallenge; in 2 patients, other drugs than metapramine might be implicated in hepatic injury; however, the similarity of these 3 cases suggests that metapramine, like other tricyclic antidepressants, may be responsible for hepatic injury.

[Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography performed during the same anesthesia session]. / Echo-endoscopie et cholangio-pancréatographie rétrograde endoscopique dans un même temps anesthésique.

OBJECTIVES: To evaluate the feasibility, results and importance of a diagnostic and therapeutic biliary and pancreatic exploration associating endoscopic ultrasonography and endoscopic retrograde cholangio-pancreatography during the same anaesthesia session. METHODS: From November 1997 to October 1998, 179 patients (83 males, 96 females), mean age 62 years (range 22 to 95 years), were investigated in our gastroenterology unit for biliary or pancreatic disorders. Two hundred and sixty two examinations were performed by a single physician for patients under general anaesthesia. In 87 cases (42%), endoscopic retrograde cholangio-pancreatography was performed immediately without prior endoscopic ultrasonography; these patients were not included. When endoscopic retrograde cholangio-pancreatography followed endoscopic ultrasonography, it was performed during the same anaesthesia session. RESULTS: In 118 cases, endoscopic ultrasonography was performed first, followed by endoscopic retrograde cholangio-pancreatography 57 times (48%). The sensitivity of endoscopic ultrasonography was 96.5% and the success of therapeutic endoscopic retrograde cholangio-pancreatography was 100%. Endoscopic retrograde cholangio-pancreatography was necessary for 83% of patients with angiocholitis, 60% with cholestasis, 45% with acute biliary pancreatitis and only 28% with common bile duct stone migration. CONCLUSION: To decrease the number of anaesthesia sessions, endoscopic ultrasonography--endoscopic retrograde cholangio-pancreatography during same anaesthesia session appears to be particularly interesting for the diagnosis and treatment of biliary and pancreatic disorders, in terms of cost, accuracy, morbidity and patient comfort.

[Hepatitis caused by clometacin (Dupéran). Retrospective study of 30 cases. A model of autoimmune drug-induced hepatitis?]. / Hépatites à la clométacine (Dupéran). Etude rétrospective de 30 cas. Un modèle d'hépatite auto-immune médicamenteuse?

Thirty cases of clometacin-induced hepatitis were retrospectively collected over a nine-year period in hepatogastroenterological units of non university, public hospitals. There was a strong female predominance (90 percent). Clometacin (Dupéran) was taken because of arthritis in 8 out of 10 cases. Administration was continuous in 85 percent of cases and median duration was 445 days. median dose was 450 mg per day. Jaundice, fatigue, and weight loss were the most frequent symptoms, but edema, ascites and palmar erythema were not uncommon. Thrombopenia (38 percent) was the most frequent hematologic abnormality. Renal failure, always with benign course, was present in 1/4 of cases. Biochemical disorders indicated hepatocellular and cholestatic hepatitis in 3/4 and 1/4 of cases respectively. Hypoprothrombinemia below 50 percent was noted in 1 out of 6 cases, and was associated with death in half cases. Gamma-globulins were increased in 80 percent of cases, with a predominant increase of IgG. Antinuclear or anti-smooth muscle antibodies were present in 60 percent of cases, whereas antimitochondrial and antimicrosomes were absent. Histopathological examination of the liver biopsy specimens obtained in 25 patients showed acute hepatitis in 8 and chronic active hepatitis with fibrosis in 17--including 6 patients with cirrhosis; there were no epidemiological, clinical (except ascites), or biochemical differences between these two groups. Four of the 7 patients tested had HLA B8 antigens; they all had chronic active hepatitis, with autoantibodies in 3 cases. Median duration of hospitalization was 21 days. Hepatitis was directly responsible for death in 3 patients; biochemical sequelae (hypergammaglobulinemia or anicteric cholestasis) were present in 8 patients, 2 of whom most likely had cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Does continuous enteral nutritional deficiencies in digestive system diseases? Results of a longitudinal study of 92 consecutive patients treated for 3 to 7 weeks]. / L'alimentation entérale continue corrige-t-elle la dénutrition des affections digestives? Résultats de l'étude longitudinale de 92 malades consécutifs traités pendant trois à sept semaines.

In order to assess the effectiveness and potential limitations of continuous enteral nutrition (CEN) to correct denutrition related to underlying digestive diseases, 10 nutritional criteria were measured weekly in 92 under-nourished patients fed with CEN for a 3-7 week period. All the patients received a standard non-elemental diet providing a mean daily energy intake of 52.8 kcal/kg BW (36.5 kcal/kg BW by tube feeding and 16.3 kcal/kg BW orally). The influence of preexisting intestinal malabsorption, hypercatabolic status, and post-radiation or inflammatory bowel disease was studied by an a posteriori classification of patients in one of the six following groups: I (no limiting factor), II (malabsorption), III (catabolic disease), IV (catabolic disease and malabsorption), V (colitis), VI (enteritis). During CEN, 8 patients had transient and one had persistent vomiting while 3 developed bronchopneumonia. Gains in body weight, triceps skinfold, midarm muscle circumference, creatinine-height index, urinary sodium and serum transferrin were significant as early as the 2nd week of CEN. Serum albumin and cholesterol, hemoglobin, and total count of lymphocytes were not significantly affected. Sixty-five patients (71 per cent) had an objective nutritional improvement and mean spontaneous oral intake increased from 17.8 to 28.7 kcal/kg BW per day. Significant increase of oral intake and objective nutritional improvement were observed in each group, but a longer period of CEN was necessary to achieve this result in groups II, IV and VI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mixed endocrine tumor of the pancreas (vipoma, glucagonoma). Treatment by somatostatin followed by one of its long-acting analogs]. / Tumeur mixte du pancréas endocrine (vipome, glucagonome). Traitement par la somatostatine puis par un de ses analogues d'action prolongée.

We describe the 4-year follow-up of an endocrine tumour of the pancreas (vipoma-glucagonoma) treated with chemotherapy. To control the endocrine syndrome we used somatostatin 14 by continuous subcutaneous infusion for 1 year, followed by the somatostatin analogue SMS 201-995 administered alone without antitumoral chemotherapy. Under SMS 201-995 (100 micrograms 12-hourly) the endocrine syndrome dramatically improved. This effect persisted for 12 months after which a relative resistance to the drug developed. It was necessary to increase the dosage (300-400 micrograms/24 hours) and to alter the mode of administration (continuous subcutaneous infusion) to obtain a clinical benefit inferior to that obtained during the first year of treatment with SMS 201-995. At present this drug is given combined with recombinant interferon alpha 2A. In spite of computerized tomography, ultrasonography and monitoring of hormone levels we were unable to determine whether or not SMS 201-995 exerted a partial antitumoral effect.

[Endoscopes in urology: disinfection, sterilization, labeling and tracking. Circulars and decrees. Modes of application and commentary. The Committee of Infectious Diseases of the French Association of Urology. Congressional forum UFA--Paris, November 1996. DGS Circular 20 October 1997]. / Les endoscopes en urologie: désinfection, stérilisation, marquage et traçage. Circulaires et décret. Modalités d'application et commentaires. Comité d'infectiologie de l'Association Française d'Urologie (CIAFU). Forum Congrès AFU-Paris, novembre 1996. Circulaire DGS 20 octobre 1997.

Administrative texts published in 1995, 1996 and 1997, have reinforced materiovigilance and impose disinfection precautions for endoscopes. The steps of disinfection of non-sterilizable endoscopes are: preliminary treatment, rinsing, actual disinfection, final rinsing, storage (see: Progrès en Urologie, 1997, 7, 505-507). Each procedure from collection of the endoscope until storage must be defined by written standard operating procedures validated by CLIN. The risk of transmission of Creutzfeld-Jakob disease requires autoclaving, which is only possible, at the present time, with the most recent rigid endoscopes. Until disinfection has become generalized, the traceability of endoscopes (labelling, utilization files) must be established on the model recommended for haemovigilance (circular of 02/04/96).