Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India.

BACKGROUND/PURPOSE OF THE STUDY: Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality. METHODS: Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge. RESULTS: A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis. CONCLUSION: Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.

Short-Term Outcome of Patients with Cirrhosis and Concurrent Portal Cavernoma Presenting with Acute Variceal Bleeding.

Background and Aim: The outcome of cirrhotic patients with main portal vein occlusion and portal cavernoma after the first episode of acute variceal bleeding (AVB) is unknown. We compared short-term outcomes after AVB in cirrhotic patients with and without portal cavernoma. Methods: Between January 2009 and September 2014, 28 patients with cirrhosis and portal cavernoma presenting with the first occurrence of AVB and 56 age-, sex-, and Child-Pugh score-matched cirrhotic patients without portal cavernoma were included. The primary endpoints were 5-day treatment failure and 6-week mortality. Results: The 5-day treatment failure rate was higher in the cavernoma group than in the control group (32.1% versus 12.5%; p = 0.031). The 6-week mortality rate did not differ between the cavernoma and control group (25% versus 12.5%, p = 0.137). Multivariable Cox proportional hazard regression analyses revealed that 5-day treatment failure (HR = 1.223, 95% CI = 1.082 to 1.384; p = 0.001) independently predicted 6-week mortality. Conclusions: Cirrhotic patients with AVB and portal cavernoma have worse short-term prognosis than patients without portal cavernoma. The 5-day treatment failure was an independent risk factor for 6-week mortality in patients with cirrhosis and portal cavernoma.

Causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding.

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.

Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study.

BACKGROUND & AIMS: Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy. METHODS: From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test. RESULTS: In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n=26) and 29.7% (n=30), respectively. The overall 6-week and 3-month mortality was 31.7% (n=32) and 38.6% (n=39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p=0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p=0.944) and mortality (11.8% vs. 9.1%, p=0.861). CONCLUSIONS: It is likely that early endoscopy (≤ 12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.

Early risk stratification with simple clinical parameters for cirrhotic patients with acute upper gastrointestinal bleeding.

OBJECTIVE: This study aimed to identify pre-endoscopic clinical parameters independently associated with 6-week mortality and to develop a prognostic model in cirrhotic patients with acute upper gastrointestinal (UGI) bleeding. METHODS: A total of 542 consecutive admissions of 389 cirrhotic patients with acute UGI bleeding were retrospectively investigated. Pertinent clinical data obtained at the emergency department were analyzed. Multivariate logistic regression analysis was performed to determine risk factors for 6-week mortality and to develop a predictive model. RESULTS: Forty-four patients (8.12%) died within 6 weeks. The 6-week mortality was independently associated with male sex, hepatocellular carcinoma, non-hepatocellular carcinoma malignancy, hypoxemia with peripheral oxygen saturation less than 95%, serum bilirubin, and prothrombin time. A predictive model consisting of these 6 simple parameters was built. The c statistic of our model was 0.84, significantly superior to that (0.71) of the model for end-stage liver disease score (P = .002). CONCLUSIONS: Simple pre-endoscopic clinical parameters are valuable for early risk stratification in cirrhotic patients with acute UGI bleeding. Our prognostic model warrants prospective validation by further studies.

[Hematemesis in Togo: findings of a 12-month study in an intensive care unit]. / Hématémèses au Togo: expérience d'un an en réanimation.

This prospective study was conducted over a 12-month period on patients who underwent upper digestive endoscopy for hematemesis in the medical intensive care unit (ICU) of the Tokoin University Hospital Center in Lomé, Togo. A total of 44 patients with a mean age of 44 years were included. The sex-ratio was 2.61. Risk factors included use of non-steroid anti-inflammatory (NSAI) in 16 patients (36.4%) and alcohol abuse in 13 (29.6%). At the time of admission to the ICU, 21 patients (47.7%) were in hemodynamic shock and 11 (25%) presented signs of portal hypertension. The underlying etiology was peptic ulcer in 18 cases (40.9%) including 13 cases of duodenal ulcer and 5 cases of stomach ulcer, rupture of esophageal varicosities in 8 (18.2%), gastric tumor in 6 (13.6%), Mallory Weiss syndrome in 5 (11.4%), gastritis in 4 (9,1%), and esophagitis in 3 (6.8%) due to peptic inflammation in 2 and mycotic infection in 1. The mortality rate was 45.5%. The main causes of hematemesis were peptic ulcer and rupture of esophageal varicosities. The death rate was high due to inadequate care facilities.

Correlación clínica- para-clínica en un escolar con hipertensión porta de etiología a esclarecer / Clinical-paraclinical in a school with portal hypertension to determine

La hipertensión porta (HTP) es el resultado del incremento de la presión dentro del sistema venoso porta. Se presenta con poca frecuencia en el paciente pediátrico pero es una de las mayores causas de morbilidad y mortalidad en el niño con enfermedad hepática. La mayoría de los pacientes con http presentan un estado hiperdinámico, lo cual aumenta el flujo venoso porta y mantiene la hipertensión. Puede ser secundaria a obstrucción a nivel prehepático, intrahepático o extrahehepático.

Portal hypertension (PH) is the result of increased pressure within the portal venous system. It occurs infrequently in the pediatric patient but it is a major cause of morbidity and mortality in children with liver disease. Most patients with PH have a hyperdynamic state, which increases venous flow and portal hypertension remains. May be secondary to obstruction at prehepatic, intrahepatic or extrahehepatic.

Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.

BACKGROUND AND AIMS: Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing. METHODS: Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters. RESULTS: Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27-10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07-1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54-12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06-70.94). CONCLUSION: Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.

Management of massive peptic ulcer bleeding.

Massive bleeding from a peptic ulcer remains a challenge. A multidisciplinary team of skilled endoscopists, intensive care specialists, experienced upper gastrointestinal surgeons, and intervention radiologists all have a role to play. Endoscopy is the first-line treatment. Even with larger ulcers, endoscopic hemostasis can be achieved in the majority of cases. Surgery is clearly indicated in patients in whom arterial bleeding cannot be controlled at endoscopy. Angiographic embolization is an alternate option, particularly in those unfit for surgery. In selected patients judged to belong to the high-risk group--ulcers 2 cm or greater in size located at the lesser curve and posterior bulbar duodenal, shock on presentation, and elderly with comorbid illnesses--a more aggressive postendoscopy management is warranted. The optimal course of action is unclear. Most would be expectant and offer medical therapy in the form of acid suppression. Surgical series suggest that early elective surgery may improve outcome. Angiography allows the bleeding artery to be characterized, and coil embolization of larger arteries may further add to endoscopic hemostasis. The role of early elective surgery or angiographic embolization in selected high-risk patients to forestall recurrent bleeding remains controversial. Prospective studies are needed to compare different management strategies in these high-risk ulcers.

Lethal outcome of post-tonsillectomy hemorrhage.

Despite the large number of tonsillectomies performed little knowledge exists about post-tonsillectomy hemorrhage (PTH) with lethal outcome. This study was performed to evaluate clinical features in a larger patient population with emphasis on the onset of this complication. A nationwide collection of cases was performed based on personal communication, expert reports to lawsuits and professional boards, and case reports received after a plea published in a professional national journal. Clinical data of 29 patients were collected of whom the 18 were children (64%). With one exception all patients experienced secondary PTH (>24 h) occurring 1-28 days after tonsillectomy. Aspiration contributed to lethal outcome in 13 cases. Fatalities were unavoidable although 21 patients were in the hospital. Massive vomiting of blood was observed in 11 patients. There were 11 patients without (group A) and 18 with (group B) episodes of repeated bleeding. This study suggests that particularly children are endangered by lethal PTH. Inpatient treatment was unable to prevent lethal outcome in this selected patient population. However, it appears wise to re-admit patients with delayed PTH, since excessive PTH may occur. These unexpected and unpredictable situations require an immediate and adequate medical treatment by a skilled staff. The paucity of data currently does not allow calculation of a cut-off point at which the risk of life-threatening PTH significantly decreases. Secondary PTH remains a substantial complication.

Perforation of a gastric tube peptic ulcer into the thoracic aorta.

We present a case of a 52-year-old male patient who died from massive hematemesis as a result of perforation of a benign peptic ulcer into the descending thoracic aorta, 1 year after esophagectomy for esophageal cancer and gastric tube interposition. We also review the literature for mechanisms of ulceration in intrathoracic gastric grafts and for complications of such ulcers.

Predictors of mortality in hospitalized patients with secondary upper gastrointestinal haemorrhage.

OBJECTIVES: To identify clinical, laboratory and endoscopic features of prognostic implication in patients who suffer an upper gastrointestinal haemorrhage whilst hospitalized for other causes. DESIGN/SETTING: A prospective longitudinal study of 125 consecutive cases (89 males, 36 females) seen during 1988-1991 in a tertiary care university hospital. MAIN OUTCOME MEASURES: The crude and adjusted relative risk of mortality associated with each of the various clinical, laboratory and endoscopic variables. RESULTS: The rates of endoscopic haemostasis, persistent or recurrent bleeding and surgery to control bleeding were 48, 37 and 12%, respectively; the overall mortality was 28%. A significantly increased risk of mortality was associated with shock prior to onset of bleeding, sepsis, renal failure, cirrhosis, encephalopathy, presence of red blood in the nasogastric aspirate or per rectum, thrombocytopenia, hypoalbuminaemia, elevation of serum bilirubin, aminotransferases or urea levels, endoscopic evidence of active bleeding, the application of endoscopic haemostasis, rebleeding, transfusion of > or = 6 units of blood, surgical treatment or any subsequent complication. Use of nonsteroidal anti-inflammatory drugs (27%) was associated with a decreased mortality risk (odds ratio 0.2; P = 0.03). A multivariate analysis showed that the features at presentation which were independently associated with an increased risk of mortality were: a history of cirrhosis, sepsis, shock prior to onset of bleeding, hypo-albuminaemia and elevated serum aminotransferases. CONCLUSION: The prognosis of secondary upper gastrointestinal haemorrhage depends on the underlying diseases and on the general condition of the patient, rather than on the actual cause of bleeding.

[The prognostic value of the endoscopic signs in the recurrence of peptic ulcer hemorrhage]. / Valor pronóstico de los signos endoscópicos en la recidiva de la hemorragia por ulcus péptico.

The endoscopic signs of hemorrhage in bleeding peptic ulcers are considered as prognostic factors for rebleeding and mortality. The value of these signs has been examined in several studies of patients with known high risk factors. In this survey, we studied the prognostic value of the endoscopic signs of hemorrhage in bleeding peptic ulcer in a group of patients without clinical risk factors such as age > 60 years, concomitant malignancy or respiratory and heart disease. Endoscopic findings were examined in fifty patients without rebleeding (group I) and twenty five with rebleeding (group II). Endoscopic findings results were spurting arterial bleeding in 9.3% of the cases, oozing hemorrhage in 17.3% of the cases, visible vessel in 9.3% of the cases, and adherent clot in 82.3% of the cases. In 9.3% of the cases endoscopic findings were negative. No statistical differences were found in the endoscopic signs among the two groups. The visible vessel and the spurting arterial bleeding cases presented in more than 50% of the rebleeding, (visible vessel and spurting arterial 57.1%). Oozing hemorrhage and the adherent clot were present in 30% of the cases. The endoscopic signs of bleeding can assist in choosing the group of patients with prospective high risk of rebleeding and possible candidates for the new treatment of endoscopic hemostatic therapy.

[Hematemesis. Extramural emergency]. / Hämatemesis. Spital-externer Notfall.

Hematemesis is the cardinal sign of upper gastrointestinal bleeding. It is a sign related to numerous affections, with a prognosis depending on the underlying lesion, the degree of bleeding, the accompanying disease and other risk factors. Mortality rates are generally close to 10%, although if hematemesis is secondary to variceal bleeding, as high as 30%. 65% of hemorrhages subside spontaneously, but 25% bleed recurrently (after initial cessation) and in 10% bleeding persists. Three quarters of all renewed bleeding occurs within two days after the initial hemorrhage. If hematemesis occurs outside a hospital, rapid evaluation is required to assess the necessity of emergency transport and treatment. In the case of severe to moderate bleeding, life-support measures and rapid transport to the nearest hospital are of primary importance and all measures complicating diagnosis and treatment in the hospital should be avoided. Patients with mild hematemesis, stable cardiovascular parameters and no risk factors can be investigated and, if appropriate, treated, on an out-patient basis. If the cause of hematemesis cannot be found, aggressive, inpatient investigations are required at the first sign of second bleed. Endoscopy is the primary investigative procedure for hematemesis. The success rate is highest if endoscopy is performed within the first 36 hours of the onset of bleeding. There are indications that aggressive diagnosis and therapy, including endoscopic hemostatic interventions, can reduce hematemesis mortality.

Bleeding as a cause of death in HIV-seropositive patients with congenital clotting disorders.

The causes of death in a group of HIV-seropositive patients suffering from congenital clotting disorders (cCD) were studied. During the past 6 years, we have followed 19 patients with cCD and HIV infection. Eight patients fulfilled revised CDC criteria for AIDS, 6 subjects reached stage III of CDC, and 5 remained asymptomatic (CDC stage II). All patients who developed AIDS died. In 5 patients, the terminal cause of death was a severe haemorrhage (hematemesis, melena or haemoptysis) after gastrointestinal or lung opportunistic infections. Two other patients died as a consequence of disseminated infections but without significant bleeding. Only one subject died due to neoplastic disease. In the first stages of CDC (II and III), no increase in bleeding symptoms were seen in cCD HIV infected patients. The risk of haemorrhages is, however, increased in AIDS patients. Adequate replacement therapy should be started early whenever severe opportunistic infections appear.

Haematemesis patients should be managed in special units.

This report outlines the results of 568 episodes of acute upper gastrointestinal haemorrhage managed in the Gastroenterology Unit of The Royal Newcastle Hospital during 1964-1974. In this Unit a conservative regimen of blood transfusion and surgery was used with the aim of operating immediately on the recurrence of bleeding for patients with chronic gastric ulcers. In comparison with the 523 patients who were bleeding who were treated in other medical units in the same hospital during 1964-1969, the mortality rate was lower for all peptic ulcers (4.9% compared with 10.6%; P less than 0.025) and for gastric ulcers (8.9% compared with 23.1%; P less than 0.01), but differences for duodenal ulcers (3.6% compared with 5.8%) and in the other diagnostic sub-groups were not significant. The results are also compared with those from units that manage all admissions for upper gastrointestinal bleeding at Prince Henry's Hospital, Melbourne (which has an aggressive transfusion and surgical policy), and The Royal North Shore Hospital of Sydney (which has a "standard" approach). In spite of radically different policies, all three gastrointestinal units obtained rather similar results, with the Newcastle mortality rate from bleeding ulcers of 4.9% being the lowest of all. It is suggested that all large hospitals should have haematemesis and melaena units, as they do coronary care units, but that there is no advantage to be gained by a policy of aggressive treatment.

Haematemesis and melaena at St. Vincent's Hospital, Melbourne.

One hundred and fifty-three patients with haematemesis and melaena were studied retrospectively. The majority were managed in general medical units. Fifty-one per cent had a past history of peptic ulcer and/or bleeding, and only 9% had no identifiable predisposing factors. Endoscopy was the major diagnostic tool, with a diagnostic rate of 85%. Nineteen per cent of patients had no diagnostic investigations performed for varied reasons. The operative rate was 15% overall, with an operative mortality of 17%. The presence of other serious disease states concomitant with the haematemesis and melaena, and the presence of oesophageal varices as the aetiology, were both shown to be associated with statistically worse prognoses. Age of greater than 50 years and transfusion of four or more units of blood were also associated with a worse prognosis. Overall mortality was 14%, comparable to or less than that at several institutions, but more than double that of a Haematemesis and Melaena Unit in another Melbourne hospital [Br. Med. J. 1, 1238-40 (1979)] Patient population should be considered closely when comparing mortalities from different series. It is felt that results could be improved using a combined medical and surgical approach, and a set protocol of management, and that such changes should be monitored via a prospective study.