Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome.

PURPOSE: To determine the risk factors, etiology, and outcome of clinically important gastrointestinal bleeding that occurs after hospital admission (nosocomial gastrointestinal bleeding). PATIENTS AND METHODS: Cases consisted of consecutive patients who developed gastrointestinal bleeding more than 24 hours after admission to the hospital. Cases were compared with two control populations: a set of hospitalized patients without gastrointestinal bleeding matched with cases for age, gender, and length of stay; and all patients admitted to the hospital with clinically important gastroduodenal ulcer bleeding during the study period. Case and controls were compared with respect to risk factors for gastrointestinal bleeding and outcomes. Data were obtained through a comprehensive review of medical records. RESULTS: Clinically important nosocomial gastrointestinal bleeding occurred in 67 inpatients after a mean hospital length of stay of 14 +/- 10 days. The majority (64%) of the patients were not hospitalized in the intensive care unit at the onset of the bleeding. Seventy-two percent of the patients who developed bleeding had been receiving some form of bleeding prophylaxis. In a multivariate analysis, a prior intensive care unit stay (odds ratio 2.5; 95% confidence interval 1.0 to 6.1; P <0.05) and mechanical ventilation (OR 3.4; 95% CI 1.1 to 10.7; P = 0.03) were independent risk factors for the onset of bleeding. Nosocomial gastrointestinal bleeding was associated with poor outcome, with an associated mortality of 34%. Duodenal ulcer disease was the most common source of nosocomial gastrointestinal bleeding, accounting for 36% of cases overall. Nosocomial ulcer bleeders were less likely to have a previous history of ulcer disease (13% versus 50%; P <0.05) Helicobacter pylori infection (14% versus 62%; P <0.0001), chronic active gastritis (29% versus 91%; P <0.0001), or to be taking NSAIDs (48% versus 68%; P <0.08) than patients admitted to the hospital with ulcer bleeding. CONCLUSIONS: Gastrointestinal bleeding remains an important complication of hospitalization, with a high associated mortality. Our current approaches to prevention of this complication are imperfect. Bleeding tends to occur after a prolonged hospital stay and is more likely to occur in patients with more severe underlying illnesses. Duodenal ulcer disease is the most common source of this bleeding. Nosocomial gastroduodenal ulcer disease is distinct in etiology from the ulcer disease that occurs in outpatients.

The management of T tube leaks in orthotopic liver transplant recipients with endoscopically placed nasobiliary catheters.

Biliary tract problems remain an important cause of complication following orthotopic hepatic transplantation. We describe 12 liver transplantation patients who developed bile peritonitis secondary to a biliary leak after T tube removal. Each of these patients underwent an urgent ERCP that exhibited leakage outside the T tube tract and nondilated intrahepatic ducts. At the time of the ERCP, a nasobiliary catheter was inserted to divert the bile flow. All of these patients resolved their symptoms and closed their leak. We advocate endoscopic placement of a nasobiliary catheter as first-line therapy for significant T tube tract leaks after liver transplantation.

Thoracoscopic esophageal myotomy in the treatment of achalasia.

We treated 24 patients with achalasia using thoracoscopic (22 patients) or laparoscopic (2 patients) esophagomyotomy. The only operative complications were mucosal lacerations, which occurred in 3 patients and required conversion to an open procedure in 2. Twenty-two (91%) patients were eating by the second postoperative day. Analgesics were only required for the management of pain from the chest tube, which remained in place for a median time of 24 hours. The median postoperative hospital stay was 3 days (range, 20 to 14 days). The myotomy proved to be incomplete in the first 3 patients, who required a second myotomy; this was done laparoscopically in 2. One patient had a paraesophageal hernia repaired 6 months after the myotomy, and 1 patient required an esophagectomy 1 year after the myotomy for a large nonfunctioning esophagus. Late follow-up showed that swallowing was excellent in 17 (71%) and fair to good in 4 (17%). Sixteen (66%) of these 24 patients have regained their original weight. Thus, excellent to good results were ultimately obtained in nearly 90% of the patients. These results suggest that esophageal myotomy performed using minimally invasive techniques appears to be the treatment of choice for achalasia.

Post-transplant biliary problems.

Biliary problems after a liver transplantation constitute the most frequent source of morbidity. Early recognition and nonoperative therapy have impacted short-term survival. Endoscopic therapy is the cornerstone in the initial treatment of all post-transplant biliary complications. A multidisciplinary approach involving endoscopic, percutaneous, and surgical therapies are often complementary in the management of these complex patients.

The effect of ethanol on heme and porphyrin synthesis.

Despite the inherent difficulties in interpreting in vivo data on the effects of alcohol, it appears quite evident that ethanol itself alters the metabolism of the porphyrins and in so doing directly influences heme and hemoglobin synthesis. The mechanism of ethanol-induced iron overload remains elusive but, through observing the effects of phlebotomies and rechallenge with iron, the relationships of iron and alcohol to porphyria cutanea tarda are being more clearly defined. The control mechanisms of porphyrin synthesis by endogenous factors may be part of a more general red blood cell regulatory apparatus.

Risk of persistent or recurrent and intractable upper gastrointestinal bleeding in the era of therapeutic endoscopy.

OBJECTIVES: Patients who present to the emergency department with upper gastrointestinal bleeding can have persistent or recurrent (further) bleeding or self-limited bleeding. We performed a study to determine the frequency, risks factors, and impact on outcome of further bleeding. METHODS: Clinical predictors of further bleeding were retrospectively identified in 137 consecutive patients presenting to our institution with upper gastrointestinal bleeding in 1994-1995. RESULTS: Persistent or recurrent bleeding occurred in 30.7% of the cases, bleeding intractable to endoscopic therapy occurred in 15.3%. Hematemesis (odds ratio [OR] 5.7; 95% confidence interval [CI], 2.4-13.1, p = 0.0001) and a initial hemoglobin (OR, 0.8; 95% CI, 0.7-0.96; p = 0.01) were independent risk factors for persistent or recurrent bleeding, whereas liver disease (OR, 6.0; 95% CI, 2.0-18.4; p = 0.002) and hematemesis were independent risk factors for intractable bleeding. The mortality rate was 14.3 and 1%, respectively, in patients with and without further bleeding. In patients who did not present with hematemesis, liver disease, coagulopathy, hypotension, and initial hemoglobin < 11 g/dl, the frequency of further bleeding and mortality was 0%. CONCLUSIONS: Persistent, recurrent, and intractable bleeding occurs in a substantial proportion of patients admitted with upper gastrointestinal bleeding. The risk of further bleeding can be estimated on the basis of clinical presentation. Further bleeding is associated with a worse outcome.

Fatal Clostridium difficile enteritis after total abdominal colectomy.

A 71-year-old man who had undergone an ileorectal anastomosis some years earlier, developed fulminant fatal Clostridium difficile pseudomembranous enteritis and proctitis after a prostatectomy. This case and three reports of C. difficile involvement of the small bowel in adults emphasize that the small intestine can be affected. No case like ours, of enteritis after colectomy from C. difficile, has hitherto been reported.

Hyperplastic gastric polyps associated with persistent Helicobacter pylori infection and active gastritis.

We report two cases of patients with 3-yr histories of upper gastrointestinal symptoms, hyperplastic gastric polyps, and active chronic gastritis. Biopsies retrospectively stained with Giemsa revealed the persistent presence of Helicobacter pylori (HP) in gastric biopsies of both patients throughout the 3 yr. After treatment with amoxicillin and bismuth subsalicylate, both became asymptomatic, one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the HP. These cases demonstrate 3 yr of hyperplastic gastric polyps associated with HP and active gastritis.

Zollinger-Ellison syndrome in a patient with normal screening gastrin level.

A 59-year-old female presented with multifocal peptic ulcer disease and diarrhea. A fasting serum gastrin level obtained while the patient was receiving no antacid therapy was normal. A secretin stimulation test was positive. A small gastrinoma was found in the anterior duodenal wall at exploratory laparotomy. Normal fasting gastrin levels do occur in patients with overt Zollinger-Ellison syndrome and should not deter further investigation if clinical suspicion of this syndrome is high.

The role of endoscopic evaluation in patients with suspected intestinal graft-versus-host disease after allogeneic bone-marrow transplantation.

BACKGROUND AND STUDY AIMS: Previous reports have suggested that endoscopic evaluation, with histological and microbiological examination of biopsied tissue, is required to diagnose gastrointestinal disease accurately in patients after allogeneic bone-marrow transplantation. We sought to further define the usefulness, yield, and sensitivity of endoscopic tissue biopsy in this patient population. PATIENTS AND METHODS: A retrospective review of the clinical, endoscopic, histological, and microbiological data was obtained during the evaluation and treatment of 61 distinct episodes of unexplained gastrointestinal complaints in 37 adult allogeneic bone-marrow transplant recipients over six years at our institution. RESULTS: Acute gastrointestinal graft-versus-host disease was found in 12 of the 61 episodes (20%). Gastrointestinal infections were found in 14 of the 61 episodes (23%); there were Herpesvirus infections (n = 8) and fungal infections (n = 9). Patients with and without graft-versus-host disease were similar in terms of their age, sex, underlying illness, clinical symptoms and signs, physical examination, laboratory values, and endoscopic findings. Small-bowel biopsy had a sensitivity of 90% for detecting the pathological changes of acute intestinal graft-versus-host disease in this series. CONCLUSION: A high percentage of patients with gastrointestinal complaints after allogeneic bone-marrow transplantation have acute gastrointestinal graft-versus-host disease, or an opportunistic infection. Gastrointestinal graft-versus-host disease cannot be accurately diagnosed from its clinical presentation. Endoscopic small-bowel biopsy is an essential tool in evaluating this patient population.

Multidisciplinary approach to complex endoscopic biliary intervention.

Endoscopy is frequently used to treat biliary abnormalities; however, controlling the catheter is difficult when tortuous structures or specific intrahepatic ducts must be negotiated. Intraductal manipulation with conventional angiographic guidance is difficult, and combined transhepatic approaches are painful, associated with risk, and cumbersome. The authors describe a multidisciplinary approach to complex endoscopic procedures in which the interventional radiologist controls catheter and guide wire placement. Of 344 procedures attempted over a 3-year period, 304 were accomplished with transendoscopic- or fluoroscopic-guided methods alone. Combined transhepatic procedures were performed in the other 40 cases. The success rate of endoscopic procedures and the number of conditions treatable with nonoperative interventional methods are increased with a multidisciplinary approach.

Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial.

BACKGROUND: Hemorrhage from esophageal varices remains a substantial management problem. Endoscopic sclerotherapy was preferred for more than a decade, but fluoroscopically placed intrahepatic portosystemic stents have recently been used with increasing frequency. OBJECTIVE: To compare sclerotherapy with transjugular intrahepatic portosystemic shunt (TIPS) in patients with bleeding from esophageal varices. DESIGN: Randomized, controlled clinical trial. SETTING: Three teaching hospitals. PATIENTS: 49 adults hospitalized with acute variceal hemorrhage from November 1991 to December 1995: 25 assigned to sclerotherapy and 24 assigned to TIPS. INTERVENTION: Patients assigned to repeated sclerotherapy had the procedure weekly. In those assigned to TIPS, an expandable mesh stent was fluoroscopically placed between an intrahepatic portal vein and an adjacent hepatic vein. MEASUREMENTS: Pretreatment measures included demographic and laboratory data. Postrandomization data included index hospitalization survival, duration of follow-up, successful obliteration of varices, rebleeding from varices, number of variceal rebleeding events, total days of hospitalization for variceal bleeding, blood transfusion requirements after randomization, prevalence of encephalopathy, and total health care costs. RESULTS: Mean follow-up (+/-SE) was 567 +/- 104 days in the sclerotherapy group and 575 +/- 109 days in the TIPS group. Varices were obliterated more reliably by TIPS than by sclerotherapy (P < 0.001). Patients having TIPS were significantly less likely to rebleed from esophageal varices than patients receiving sclerotherapy (3 of 24 compared with 12 of 25; P = 0.012). No other follow-up measures differed significantly between groups. A trend toward improved survival, which was not statistically significant, was noted in the TIPS group (hazard ratio, 0.53 [95% CI, 0.18 to 1.5]). CONCLUSIONS: In obliterating varices and reducing rebleeding events from esophageal varies, TIPS was more effective than sclerotherapy. However, TIPS did not decrease morbidity after randomization or improve health care costs. It seemed to produce better survival, but the increase in survival was not statistically significant.