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.

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.

Can pre-endoscopic assessment predict active upper gastrointestinal bleeding? A retrospective study in patients with symptoms of upper gastrointestinal bleeding outside regular working hours.

BACKGROUND/AIMS: To evaluate the usefulness of pre-endoscopic assessment for predicting active up-per gastrointestinal bleeding (UGI-B) at emergency esophagogastroduodenoscopy (E-EGD, within 6 hours). METHODOLOGY: We retrospectively analysed the medical records of patients that had an E-EGD performed outside working hours and considered 15 pre-endoscopic variables in a univariate analysis. Active UGI-Bat E-EGD was taken as end-point. RESULTS: Of 228 E-EGD performed during 75 months, 195 were motivated by the suspicion of UGI-B. We excluded 83 cases as they were hospitalised at the time of first symptoms of bleeding. Thus, 112 cases were included. The following clinical signs triggered E-EGD: hematemesis (56/50%),melena (55/49.1%), hematochezia (20/17.8%), anae- mia (7/6.2%). Patients' age was 65.5+14.2 years. Sixty nine (61.6%) cases were male. The relative risk and p-value of the variables for the presence of active bleeding at E-EGD were as follows: hematemesis: 1.54/0.3; malignancy and cirrhosis: 1.73/0.07; haemoglobin <8g/dL: 1.38/0.3; white blood count >12,000/tL: 1.18/0.6;systolic blood pressure (SBP) <100 mmHg: 0.53/0.03;pulse >100/min: 1.42/0.2; platelets <14000/nL:1.5/0.2; INR >1.17: 1.89/0.049. In the multivariate analysis none of these variables independently predicted UGI-B. CONCLUSIONS: No relevant pre-endoscopic variables for the prediction of active UGI-B at E-EGD could be found. Our data suggest that pre-endoscopic evaluation cannot replace rapid endoscopy.

Hemorragia digestiva alta en el Servicio de Gastroenterología del Instituto Nacional de Salud del Niño de Enero del 2005 a Diciembre del 2010 / Upper gastrointestinal bleeding in the Gastroenterology Service at the National Institute of Child Health from January 2005 to December 2010

En el Instituto Nacional de Salud del Niño se registraron 229 episodios de hemorragia digestiva, de los cuales se incluyeron 118 episodios de hemorragia digestiva alta (HDA) desde enero del 2005 a diciembre del 2010. Se realizó un estudio descriptivo retrospectivo. El objetivo general fue describir las El mayor número de casos se presentó en varones (51.7 por ciento). El 91.5 por ciento características epidemiológicas, etiológica, clínica y de manejo así como antecedentes patológicos de la hemorragia digestiva alta en la población pediátrica atendida en el Instituto Nacional de Salud del Niño durante el periodo de Enero del 2005 a Diciembre del 2010. La prevalencia hospitalaria fue de 1.8 por 1000 atenciones/año. Se hospitalizó por emergencia, el servicio donde fueron hospitalizados con mayor frecuencia fue en gastroenterología (67.8 por ciento). Los signos más frecuentes de presentación fueron la hematemesis y la melena. Los antecedentes patológicos más frecuentes fueron los de patología hepática, respiratoria y los gastrointestinales. El método de diagnóstico principal fue la endoscopía en el 100 por ciento de los casos. Las tres causas más frecuentes de HDA fueron várices esofágicas secundaria a hipertensión portal pre hepática en el 28 por ciento, seguido de la gastritis por medicamentos en el 26.3 por ciento y la gastritis erosiva en el 6,8 por ciento de los casos. En el 96.6 por ciento se usó tratamiento médico y solo en el 3.4 por ciento requirió manejo quirúrgico. En el 100 por ciento (118) se reportó mejoría de la HDA. En conclusión se puede decir que la HDA es una enfermedad poco frecuente y se recomienda realizar un estudio prospectivo controlado para determinar con precisión algunas variables epidemiológicas y clínicas, que ayudarían al mejor conocimiento de esta patología gastrointestinal.

Clinical profile of dengue hemorrhagic fever cases in Mexico.

OBJECTIVE: Dengue hemorrhagic fever is a public health problem in Mexico since 1994. With four serotypes circulating the risk of epidemic dengue hemorrhagic fever is increasing. MATERIAL AND METHODS: We describe the clinical features of confirmed cases in the social security health system (IMSS) from 1995 to 2003. Clinical picture and epidemiological features were compared and a multivariate model was fitted to evaluate associations. RESULTS: Cases were divided into two groups: 438 patients with dengue fever, including 109 cases with hemorrhagic manifestations without thrombocytopenia, and 977 cases with dengue hemorrhagic fever, including 79 deaths. The main risk factors associated with mortality were hematemesis (RR 2.6; CI 95% 1.4-4.6) and melena (RR 2.2; Cl 95% 1.2-3.7). CONCLUSIONS: Our results characterize the clinical profile of dengue hemorrhagic fever cases in Mexico and identify prognostic factors to alert clinician for the prevention of a fatal evolution.

Impact of the economic sanctions on duodenal ulcer in Iraq

Cases of duodenal ulcer admitted to Basra General Hospital for a one-year period prior to economic sanctions were compared with cases admitted in a one-year period during sanctions. The number of patients, age ranges, risk factors, complications, diagnosis, treatment and mortality rates were compared. The number of cases more than doubled during the period of sanctions. There was a significant increase in smoking among duodenal ulcer patients during sanctions. Other differences between the two periods were observed and reasons for these differences are discussed

The value of ultrasonography in assessment of portal hypertension in hepatosplenic schistosomiasis.

Ultrasonography can reveal most of the manifestations of portal hypertension complicating hepatosplenic schistosomiasis. However, direct demonstration of gastroesophageal varices by ultrasonography is still very difficult. An attempt was done to correlate sonographic features of portal hypertension with the degree of fibrosis to screen patients having varices and predicting their chance of bleeding. The results obtained were found to be consistent with the esophagogastric endoscopy and with history of hematemesis. Four parameters were used, size of spleen, degree of periportal fibrosis, presence of collaterals and portal vein diameter. A pilot field survey was also done adopting the same principle.

[Endoscopic assessment of hemorrhage from the gastrointestinal tract]. / Endoskopska otsenka na kruveneto ot gastro-intestinalniia trakt.

The causes of gastrointestinal bleedings was assessed by fiber gastroscopy, rectoromanoscopy and fiber colonoscopy. The most frequent causes of bleedings from the upper gastrointestinal tract are gastric and duodenal ulcers, erosive hemorrhagic gastritis, gastric cancer, liver cirrhosis with bleeding from varicose veins, polyps, diverticuli, Mallory-Weiss syndrome, etc. The most frequent causes of bleedings from the lower gastrointestinal tract are hemorrhoids, anal fissures, colonic polyps, chronic ulcerohemorrhagic colitis, rectal carcinoma, etc. The diagnostic importance of urgent endoscopic examinations is pointed out.

Bleeding peptic ulcer. Epidemiology and nonsurgical management.

Bleeding peptic ulcer remains an important problem, particularly for the elderly. Recognition of the rule of nonsteroidal anti-inflammatories in bleeding ulcer and employment of endoscopic therapeutic modalities offer promise that morbidity and mortality from bleeding ulcer may be reduced.

Electrocoagulation of actively bleeding Mallory-Weiss tears.

Thirty patients with upper gastrointestinal bleeding due to a Mallory-Weiss tear were diagnosed by endoscopy. Seventeen patients had stopped bleeding spontaneously, and 13 were actively bleeding when examined. Ten of these 13 were successfully electrocoagulated with cessation of bleeding without morbidity or mortality. Total cost and length of hospitalization were approximately one-third for those treated by electrocoagulation as compared to surgery. Endoscopic electrocoagulation of actively bleeding Mallory-Weiss tears is often successful and appears to be safe.

The economic potential and the role of aspirin and alcohol ingestion in relation to haematemesis and meleana.

The economic potential and the role of aspirin and alcohol ingestion have been explored in relation to acute upper gastrointestinal haemorrhage complicating duodenal ulcer disease or portal hypertension. Of special interest in the study was the clear indication of the relevance of socioeconomic impact in the haemorrhage patients, the majority of whom were found to belong to the class of unskilled wage earners. Though a history of regular ingestion of salicylate compounds and alcohol was commonly obtained on specific questioning, only in six of the thirty-one patients could the onset of the overt haemorrhage be attributed to adverse synergism between these two groups of drugs.