Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS: This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS: A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION: Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

Validation of a new risk score system for non-variceal upper gastrointestinal bleeding.

BACKGROUND: Recently, a new international bleeding score was developed to predict 30-day hospital mortality in patients with upper gastrointestinal bleeding (UGIB). However, the efficacy of this newly developed scoring system has not been extensively investigated. We aimed to validate a new scoring system for predicting 30-day mortality in patients with non-variceal UGIB and determine whether a higher score is associated with re-bleeding, length of hospital stay, and endoscopic failure. METHODS: A retrospective study was performed on 905 patients with acute non-variceal UGIB who were examined in our hospital between January 2013 and December 2017. Baseline characteristics, endoscopic findings, re-bleeding, admission, and mortality were reviewed. The 30-day mortality rate of the new international bleeding risk score was calculated using the receiver operating characteristic curves and compared to the pre-endoscopy Rockall score, AIMS65, Glasgow Blatchford score, and Progetto Nazionale Emorragia Digestiva score. To verify the variable for the 30-day mortality of the new scoring system, we performed multivariate logistic regression using our data and further analyzed the score items. RESULTS: The new international bleeding scoring system showed higher receiver operating characteristic (ROC) curve values in predicting mortality (area under ROC curve 0.958; [95% confidence interval (CI)]), compared with such as AIMS65 (AUROC, 0.832; 95%CI, 0.806-0.856; P < 0.001), PNED (AUROC, 0.865; 95%CI, 0.841-0.886; P < 0.001), Pre-RS (AUROC, 0.802; 95%CI, 0.774-0.827; P < 0.001), and GBS (AUROC, 0.765; 95%CI, 0.736-0.793; P < 0.001). Multivariate analysis was performed using our data and showed that the 30-day mortality rate was related to multiple comorbidities, blood urea nitrogen, creatinine, albumin, syncope at first visit, and endoscopic failure within 24 h during the first admission. In addition, in the high-score group, relatively long hospital stay, re-bleeding, and endoscopic failure were observed. CONCLUSION: This is a preliminary report of a new bleeding score which may predict 30-day mortality better than the other scoring systems. High-risk patients could be screened using this new scoring system to predict 30-day mortality. The use of this scoring system seemed to improve the outcomes of non-variceal UGIB patients in this study, through proper management and intervention.

Video capsule endoscopy for upper gastrointestinal hemorrhage in the emergency department: A systematic review and meta-analysis.

OBJECTIVE: The assessment of the severity of upper gastrointestinal hemorrhage in emergency department (ED) patients is difficult to assess with commonly available diagnostic tools. Small studies have shown that video capsule endoscopy (VCE) is a promising risk-stratification method and may be better than current clinical decision rules such as the Rockall score and the Glasgow Blatchford score. This review aims to assess the accuracy of VCE to detect active upper gastrointestinal hemorrhage compared to a reference standard. METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was used to perform a review of studies that have measured the diagnostic accuracy of VCE. Studies were included if they measured ED use of VCE for upper GI hemorrhage as compared to a reference standard of an esophagogastroduodenoscopy (EGD). A meta-analysis was performed on select patients using a fixed effects and random-effects model to determine the primary outcome of diagnostic test accuracy. RESULTS: 40 studies were screened for eligibility and five studies representing 193 patients met the inclusion and exclusion criteria. All patients received both a VCE and an EGD. The sensitivity and specificity of VCE were 0.724 and 0.748, respectively. The diagnostic odds ratio was 6.29 (95% CI: 3.23-12.25) and the summary receiver operating characteristic curve was 0.782. CONCLUSIONS: VCE demonstrated high accuracy for detecting upper GI hemorrhage in this meta-analysis of existing studies. In light of the potential advantages of VCE in the ED, further research is warranted to further establish its role.

The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding.

BACKGROUND: Acute upper gastrointestinal bleeding (UGIB) remains a major cause of hospital admission worldwide. The recent UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on severe gastrointestinal bleeding used the Shock Index to assess bleeding severity and found an association between Shock Index and mortality. However, this has never been prospectively validated as a predictor of outcome in UGIB. AIMS: To compare the Shock Index with existing pre-endoscopic UGIB risk scores in predicting outcomes after UGIB METHODS: In an international, prospective study of 3012 consecutive patients with UGIB, we compared the Shock Index with existing scores including the Glasgow Blatchford score (GBS), admission Rockall score, AIMS65, and the newly described "ABC" score. Pre-determined endpoints were need for major (≥4 units red cells) transfusion, need for endoscopic therapy and 30-day mortality. RESULTS: The Shock Index was inferior to the GBS in predicting need for major transfusion (area under the receiver operator characteristic curve [AUROC] 0.655 vs 0.836, P < 0.001) and need for endotherapy (AUROC 0.606 vs 0.747, P < 0.001). The Shock Index was inferior to all other scores for 30-day mortality: for example, AUROC 0.611 vs 0.863 for ABC score (P < 0.001). Adding the Shock Index to the ABC score did not improve accuracy of the ABC score in predicting mortality (AUROC 0.864 vs 0.863, P = 0.95). CONCLUSION: The Shock Index performed poorly with AUROCs <0.66 and was inferior to existing pre-endoscopy scores at predicting major clinical endpoints after UGIB. We found no clear evidence that the Shock Index is clinically useful at predicting outcomes in UGIB. [Correction added on 20 December 2019, after first online publication: Summary section has been changed for clarification.].

Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis.

BACKGROUND: Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)? OBJECTIVES: To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB. MATERIALS AND METHODS: We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms "gastrointestinal bleeding"; "gastrointestinal hemorrhage"; "embolization"; "embolization, therapeutic"; and "surgery" were used (("gastrointestinal bleeding" or "gastrointestinal hemorrhage") and ("embolization" or "embolization, therapeutic") and "surgery")). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention. RESULTS: Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature.Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I 2 = 43% [random effects]). Significant heterogeneity was found among the studies.Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I 2 = 4% [fixed effects]).Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I 2 = 26% [fixed effects]).Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I 2 = 56% [random effects]). A great degree of heterogeneity was found among the studies. CONCLUSIONS: The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials. LIMITATIONS: The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.

Efficacy of a novel hemostatic adhesive powder in patients with refractory upper gastrointestinal bleeding: a pilot study.

BACKGROUND: A new hemostatic adhesive powder (UI-EWD) has been developed to reduce the high re-bleeding rates associated with the currently available hemostatic powders. The current study aimed to assess the efficacy of UI-EWD as a salvage therapy for the treatment of refractory upper gastrointestinal bleeding (UGIB). METHODS: A total of 17 consecutive patients who had failed to achieve hemostasis with conventional endoscopic procedures and had undergone treatment with UI-EWD for endoscopic hemostasis in refractory UGIB were prospectively enrolled in the study. We evaluated the success rate of initial hemostasis and rate of re-bleeding within 30 days. RESULTS: All patients underwent successful UI-EWD application at the bleeding site. Initial hemostasis occurred in 16/17 patients (94 %). Re-bleeding within 30 days occurred in 3/16 patients (19 %) who had achieved initial hemostasis. In the second-look endoscopy after 24 hours, hydrogel from UI-EWD was found attached at the bleeding site in 11/16 patients (69 %). CONCLUSION: UI-EWD has a high success rate for initial hemostasis in refractory UGIB and shows promising results in the prevention of re-bleeding.

Peptic Ulcer Is the Most Common Cause of Non-Variceal Upper-Gastrointestinal Bleeding (NVUGIB) in China.

BACKGROUND This study aimed to discover the common cause of non-variceal upper-gastrointestinal bleeding (NVUGIB) by conducting a multi-center retrospective study from 2008 to 2012. MATERIAL AND METHODS Hospitalized patients ages ≥18 years old, from 8 hospitals in China, diagnosed with NVUGIB by endoscopy from 1 January 2008 to 31 December 2012 were enrolled. Questionnaires were developed and a data-entry graphical user interface was designed by using EpiData software. RESULTS Total of 2977 hospitalized patients from 8 medical centers were included. A total of 95.47% (2842/2977) of patients were admitted to a general ward, 3.53% (105/2977) were admitted to an emergency ward, and 1.00% (31/2977) were admitted to an intensive care unit. Peptic ulcer remained the most common cause of NVUGIB (73.26%), but there was a declining trend in its constituent ratio, from 2008 to 2012. A total of 14.41% (429/2977) of patients had co-morbid conditions, 92.85% (2764/2977) used proton-pump inhibitors (PPIs) prior to endoscopic treatment, 19.65% (585/2977) underwent emergency endoscopy, and 23.45% (698/2977) received a transfusion of red blood cell suspensions. A total of 5.34% (159/2977) underwent endoscopic therapy, with a treatment rate of 16.9% in high-risk peptic ulcer patients (96/568). A total of 7.69% (237/2977) were administered aspirin, of whom 32.50% (77/237) resumed aspirin intake after gastrointestinal bleeding was controlled. The median length of hospitalization was 8 days (IQR, 5-11) and the mortality rate was 1.71% (51/2977). CONCLUSIONS Peptic ulcer was still the most common cause of NVUGIB in China. The proportion of patients with high-risk peptic ulcer bleeding who received endoscopic therapy was 16.9%. Only 19.65% of NVUGIB patients underwent emergency endoscopy.

Non-variceal upper gastrointestinal bleeding.

Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.

Endoscopic Findings of Upper Gastrointestinal Involvement in Primary Vasculitis.

BACKGROUND/AIMS: Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis. METHODS: Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records. RESULTS: Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis. CONCLUSIONS: Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

Management of Upper Gastrointestinal Bleeding in Children: Variceal and Nonvariceal.

Upper gastrointestinal (UGI) bleeding is generally defined as bleeding proximal to the ligament of Treitz, which leads to hematemesis. There are several causes of UGI bleeding necessitating a detailed history to rule out comorbid conditions, medications, and possible exposures. In addition, the severity, timing, duration, and volume of the bleeding are important details to note for management purposes. Despite the source of the bleeding, acid suppression with a proton-pump inhibitor has been shown to be effective in minimizing rebleeding. Endoscopy remains the interventional modality of choice for both nonvariceal and variceal bleeds because it can be diagnostic and therapeutic.

Upper gastrointestinal bleeding.

Upper gastrointestinal (GI) bleeding remains a commonly encountered diagnosis for acute care surgeons. Initial stabilization and resuscitation of patients is imperative. Stable patients can have initiation of medical therapy and localization of the bleeding, whereas persistently unstable patients require emergent endoscopic or operative intervention. Minimally invasive techniques have surpassed surgery as the treatment of choice for most upper GI bleeding.

New vascular disrupting agents in upper gastrointestinal malignancies.

Antivascular approaches aim to cause rapid and catastrophic shutdown in the vascular function of the tumour, leading to extensive tumour cell death. Tumour vascular disrupting agents (VDAs) are a new class of cancer therapies that target the existing vasculature of tumours, taking advantage of the relative instability of tumour vasculature and its supporting structures. Treatment with VDAs induces a rapid collapse and regression of tumour vessels, with a consequent deprivation of blood and oxygen which leads to ischemic or hemorrhagic necrosis of the tumour. In this review, an overview of the most recently developed vascular disrupting agents is reported, focusing on the biological effects exerted by these compounds on endothelial cells and tumour vasculature, potentially effective in the treatment of several malignancies including upper gastrointestinal tumours. In particular, we have focused on the antimitotic agent combretastatin and its numerous synthetic analogues such as combretastatin A-4-phosphate, OXI4503, and AVE8062, and on the colchicine analogue ZD6126.

Blood transfusion for upper gastrointestinal bleeding: is less more again?

BACKGROUND: The hemoglobin threshold for transfusion of red blood cells in patients with acute gastrointestinal (GI) bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. OBJECTIVE: The objective was to prove that the restrictive threshold for red blood cell transfusion in patients with acute upper GI bleeding (UGIB) was safer and more effective than a liberal transfusion strategy. RESULTS: In total, 225 patients assigned to the restrictive strategy (51%) and 65 assigned to the liberal strategy (15%) did not receive transfusions (P <0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% versus 91%; hazard ratio (HR) for death with restrictive strategy, 0.55; 95% confidence interval (CI) 0.33 to 0.92; P = 0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group and in 16% of the patients in the liberal-strategy group (P = 0.01), and adverse events occurred in 40% and 48%, respectively (P = 0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (HR 0.70, 95% CI 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (HR 0.30, 95% CI 0.11 to 0.85) but not in those with cirrhosis and Child-Pugh class C disease (HR 1.04, 95% CI 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P = 0.03) but not in those assigned to the restrictive strategy. CONCLUSIONS: Compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute UGIB.

Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage?

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.

Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage.

BACKGROUND: Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). METHODS: From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45-90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. RESULTS: The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001). CONCLUSION: Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.