Middle-term mortality and re-bleeding after initial diverticular bleeding: A nationwide study of 365 mostly elderly French patients.

BACKGROUND AND AIMS: The aim of this study was to determine the mortality and re-bleeding rates, and the risk factors involved, in a cohort of patients with previous diverticular bleeding (DB). METHODS: In 2007, data on 2462 patients with lower gastrointestinal (GI) bleeding were collected prospectively at several French hospitals. We studied the follow-up of patients with DB retrospectively. The following data were collected: age, mortality rates and re-bleeding rates, drug intake, surgery and comorbidities. RESULTS: Data on 365 patients, including 181 women (mean age 83.6 ± 9.8 years) were available. The median follow-up time was 3.9 years (IQR 25-75: 1.7-5.4). Of these, 148 patients died (40.5%). Among the 70 patients (19.2%) who had at least one re-bleeding episode, nine died and three underwent surgical procedures. Anticoagulation and antiplatelet therapy was discontinued in 70 cases (19.2%). The independent risk factors contributing to mortality were age > 80 years (HR = 3.18 (2.1-4.9); p < 0.001) and a Charlson comorbidity score > 2 (1.91 (1.31-2.79); p = 0.003). Discontinuation of therapy was not significantly associated with a risk of death due to cardiovascular events. No risk factors responsible for re-bleeding were identified, such as antiplatelet and anticoagulant therapy in particular. CONCLUSIONS: In this cohort, the rates of mortality and DB re-bleeding after a median follow-up time of 3.9 years were 19.2% and 40.5%, respectively. The majority of the deaths recorded were not due to re-bleeding.

Eosinophilic gastrointestinal disorders associated with autoimmune connective tissue disease.

OBJECTIVES: To determine the clinical and pathological characteristics of eosinophilic gastrointestinal disease (EGID) associated with autoimmune connective tissue disease (CTD). METHODS: Systematic literature review. RESULTS: Twenty cases of CTD associated with EGID were identified. Systemic lupus erythematosus was the main EGID-associated CTD (35%), followed by rheumatoid arthritis (20%), systemic sclerosis or inflammatory myopathies (15%, each), and Sjögren's syndrome, scleromyositis or other overlapping connective tissue disease (5%, each). No patient had a history of atopy. In contrast with classical EGID among which eosinophilic esophagitis is the most frequent type, eosinophilic gastritis and/or enteritis represented 95% of cases. Gastrointestinal symptoms were often unspecific. Peripheral eosinophilia was found in 67% of cases. Upper and lower gastrointestinal endoscopy showed abnormal findings in only 40% and 30% of cases, respectively. EGID was confirmed by evidence of digestive eosinophilic infiltration, mainly in mucosal or submucosal layer. In all but one patient, the CTD was diagnosed prior to the occurrence of the EGID. In total, 95% of EGID had a favorable outcome, with corticosteroids being used in almost all cases. CONCLUSION: Clinicians should consider EGID as a possible diagnosis and perform gastrointestinal tract biopsies in patients with CTD presenting with gastrointestinal symptoms and unexplained eosinophilia. Conversely, more rarely extra-digestive features during follow-up in patients with EGID may lead to a diagnosis of an associated CTD. More research is needed to better understand the underlying pathophysiological processes leading to eosinophilic gastrointestinal infiltration in patients with CTD.

[Application of the recommendations of the conference of consensus in front of symptoms ENT, respiratory or thoracic pains considered as due to a gastroesophageal reflux disease]. / Application des recommandations de la conférence de consensus devant des symptômes ORL, respiratoires ou des douleurs thoraciques considérés comme dus à un reflux gastro-œsophagien.

AIMS: The primary objectives of this observatory were: (1) to assess the prevalence of extradigestive symptoms (EDS) (asthma, pharyngeal pain, chronic hoarseness, nocturnal breathlessness, chronic or nocturnal cough, non-cardiac chest pain) which are suspected of being associated with gastro-oesophageal reflux (GERD) in a population consulting in general practice; (2) to compare the diagnostic and therapeutic approach adopted initially and at follow-up to the recommendations of the French-Belgian Consensus Conference on adult GERD (1999). METHODS: The survey was conducted among 578 general practitioners (GPs). All EDS were investigated in patients (≥ 18 y.o.) consulting over 3 days. Only patients considered a priori as having GERD related EDS were included in study. At each visit (initial and at 1 and 4 months), the diagnostic and therapeutic approach was analyzed, scored, and the GP's certainty regarding the accountability of GER in the EDS rated using the visual analogue scale (VAS). The criteria used by GPs to evaluate GER accountability as certain or doubtful were examined. RESULTS: Out of 33,487 consulting patients, 14% presented EDS (cough: 6.7%; ENT symptoms: 7.7%; chest pain: 2.3%). Among patients presenting EDS, 22% (1063) were included in the study based on suspicion of GERD, whereas 45% (481) had neither history nor digestive symptoms typically associated with GERD. The diagnostic approach did not vary whether the patient presented typical EDS associated symptoms (A+) or not (A-): 83.7% of patients (A+) versus 86.5% (A-) immediately received acid reflux treatment; 4.6% (A+) versus 7.9% (A-) underwent additional testing and 5.2% (A+) versus 4.4% (A-) were referred to a specialist. In 87% of cases, acid reflux treatment included a proton pump inhibitor (PPI) (half-dose: 47.2%, standard dose 50.3%, double dose 2.5%); in 8.1% of patients initial acid reflux treatment included an H2 antagonist while in 3.2% of patients treatment included prokinetic drugs. At 4 months of follow-up, GERD accountability was considered certain in 74.7% of the patients included in the assessment (794/1063). The GPs opinion was based on response to acid reflux treatment in 92% of cases, on endoscopy in 6.7% of cases, on pH monitoring in 0.3% of cases and on a specialist's opinion in 6% of cases. CONCLUSION: There is a considerable difference between the recommendations of the French-Belgian Consensus Conference on adult GERD and the practices observed in general medicine. The diagnostic and therapeutic approaches were empirical with recourse to additional exams in less than 10% of cases. The degree of certainty as to GERD accountability was based primarily on response to PPI treatment.

Epidemiology and adherence to guidelines on the management of bleeding peptic ulcer: a prospective multicenter observational study in 1140 patients.

BACKGROUND AND OBJECTIVE: Mortality of upper gastrointestinal bleeding seems declining. Whether practice guidelines for the management of peptic ulcer bleeding are followed is unknown. We aimed to update epidemiology of peptic ulcer bleeding and to assess the adherence to guidelines in the French community. METHODS: Between March, 2005 and February, 2006, a prospective multicenter study was conducted including all patients with communautary upper gastrointestinal bleeding. Data from patients with peptic ulcer bleeding were extracted and analyzed. RESULTS: Out of 3203 analyzable patients included, 1140 (35.6%) had a peptic ulcer bleeding and 965 of them a duodenal and/or gastric ulcer. Seven hundred and thirty-five were male (64.5%) and mean age was 66.4 years (±18.8). Overall, 699 patients (61.3%) were taking medication inducing upper gastrointestinal bleeding. Two-hundred and sixty-eight (23.5%) patients had endoscopic therapy, 190 (70.9%) of whom had epinephrine injection alone. Among the 349 patients with high risk stigmata on endoscopy (Forrest IA, IB, IIA), 209 (59.9%) underwent endoscopic therapy. One thousand one hundred and seven patients (97.1%) were given proton-pump inhibitors. One hundred and thirty-four patients (11.8%) experienced haemorrhagic recurrence. Forty-eight patients (4.2%) underwent surgery and 61 (5.4%) died. CONCLUSIONS: Consistently with previous studies, mortality of upper gastrointestinal bleeding seems declining. Further progress lies above all in prevention but also probably in better adherence to therapeutic guidelines and management of comorbidities.

Management of bleeding peptic ulcer in France: a national inquiry.

AIMS OF THE STUDY: To evaluate and compare management practices in France for bleeding peptic ulcers using a national inquiry of university and non-university hospitals. METHOD: Responses to questionnaires sent to 812 gastroenterologists, 496 practicing in non-university hospitals and 316 in university hospitals, were compared. RESULTS: An analysis was possible in 279 (34% response rate) of the questionnaires. Forrest classification was used more frequently in university hospitals (83% vs 60%, P<0.01). Endoscopic hemostatic therapy was used more frequently in university hospitals for Forrest Ib (92% vs 81%, P=0.02), IIa (93% vs 73%, P<0.001), and IIb (58% vs 29%, P<0.001) ulcers. Injection therapy, mainly epinephrine, was the first-intention treatment for 99% of the responding gastroenterologists. Proportions of clinicians employing hemoclips (27%) or argon plasma coagulation (21%) were similar in both types of practice. Anti-secretory treatment included mainly omeprazole (82%), given intravenously (76%), sometimes as bolus i.v. doses followed by i.v. high-dose continuous infusion (15%) with some variations according to the type of hospital. In the event of recurrent or persistent bleeding, surgery was more frequent in non-university hospitals. When rebleeding occurred, a second endoscopic treatment was performed in about one quarter of patients. CONCLUSION: In France, management practices for bleeding peptic ulcer vary between university and non-university hospitals.