Recurrence rates and risk factors in obscure gastrointestinal bleeding.

Obscure gastrointestinal bleeding (OGIB), defined in 2010, involves bleeding from the GI tract that remains unexplained after standard diagnostic procedures. OGIB, which accounts for about 5% of all GI bleeds, poses diagnostic and management challenges, particularly due to the anatomical features of the small intestine. Advances in capsule endoscopy (CE) and balloon-assisted endoscopy have improved the diagnostic and therapeutic landscape for small intestinal lesions. Objective: To determine the recurrence rate and identify risk factors for recurrence following diagnostic and therapeutic interventions using CE and balloon-assisted endoscopy in patients with OGIB. Methods: A retrospective cohort study at Gifu University Hospital analyzed CE procedures for patients with OGIB from 2008 to 2022. Patients underwent CE with subsequent treatments based on the findings. Statistical analyses, including Kaplan-Meier and Cox proportional hazards models, were used to estimate cumulative recurrence rates and identify recurrence risk factors. Results: Out of 417 patients, 65.2% had positive CE findings, leading to therapeutic interventions in 16.3% of cases. The cumulative recurrence rates at 12, 24, and 36 months were 4.3%, 9.0%, and 13.9%, respectively. Liver cirrhosis (hazard rate: 4.15, 95% confidence interval 1.88-9.18, p < 0.01) was identified as a significant risk factor for recurrence. Conclusions: A significant recurrence rate in OGIB patients, with liver cirrhosis being a major risk factor. Despite diagnostic and therapeutic advances, a comprehensive approach including careful follow-up and consideration of risk factors is essential for management.

Appendicitis after endoscopic band ligation for massive ileocecal hemorrhage.

A 68-year-old man was admitted with hematochezia. Emergency computed tomography showed multiple diverticula throughout the colon. Initial colonoscopy on day 2 showed no active bleeding, but massive hematochezia on day 3 led to the performance of an emergency endoscopy. Substantial bleeding in the ileocecal area obscured the visual field, making it challenging to view the area around the bleeding site. Two endoscopic band ligations (EBLs) were applied at the suspected bleeding sites. Hemostasis was achieved without active bleeding after EBL. However, the patient developed lower right abdominal pain and fever (39.4°C) on day 6. Urgent computed tomography revealed appendiceal inflammation, necessitating emergency open ileocecal resection for acute appendicitis. Pathological examination confirmed acute phlegmonous appendicitis, with EBLs noted at the appendiceal orifice and on the anal side. This case illustrates the efficacy of EBL in managing colonic diverticular bleeding. However, it also highlights the risk of appendicitis due to EBL in cases of ileocecal hemorrhage exacerbated by poor visibility due to substantial bleeding. Endoscopists need to consider this rare but important complication when performing EBL in similar situations.

Clinical usefulness and acceptability of small-bowel capsule endoscopy with panoramic imaging compared with axial imaging in Japanese patients.

Objectives: We aimed to evaluate the usefulness and acceptability of CapsoCam Plus (CapsoCam) in Japanese patients. Methods: This retrospective single-center study enrolled 930 patients with suspected small-bowel bleeding (SSBB) who underwent capsule endoscopy. Thirty-three patients using CapsoCam and PillCam SB3 (SB3) were matched using propensity score matching. The diagnostic yield and the acceptability of CapsoCam were evaluated. Results: There was no SSBB case where capsule endoscopy was performed within 48 h of bleeding. CapsoCam had a significantly higher observation rate of the entire small bowel (97% vs. 73%, p = 0.006) and Vater's papilla (82% vs. 15%, p < 0.001) than SB3. The reading time of CapsoCam was significantly longer than that of SB3 (30 vs. 25 min, p < 0.001), and CapsoCam's time from the capsule endoscopy swallowing to read completion was longer than that of SB3 (37 vs. 12 h, p < 0.001). The two groups showed no difference in the capsule endoscopy findings according to the P classification. Notably, 85% of the patients using CapsoCam reported examination distress as "not at all" or "almost not," and 94% reported swallowing difficulty as "very easy" or "easy." Conclusions: CapsoCam took time to read; however, it is a well-tolerated examination with a high observation rate of Vater's papilla and entire small-bowel mucosa. Detectability of bleeding sources was comparable in both modalities for cases of occult SSBB and overt SSBB more than 48 h after bleeding. CapsoCam is a useful modality for patients with SSBB.

Establishment of a swine model of delayed bleeding after endoscopic procedure.

Objectives: Although delayed bleeding after endoscopic procedures has become a problem, currently, there are no appropriate animal models to validate methods for preventing it. This study aimed to establish an animal model of delayed bleeding after endoscopic procedures of the gastrointestinal tract. Methods: Activated coagulation time (ACT) was measured using blood samples drawn from a catheter inserted into the external jugular vein of swine (n = 7; age, 6 months; mean weight, 13.8 kg) under general anesthesia using the cut-down method. An upper gastrointestinal endoscope was inserted orally, and 12 mucosal defects were created in the stomach by endoscopic mucosal resection using a ligating device. Hemostasis was confirmed at this time point. The heparin group (n = 4) received 50 units/kg of unfractionated heparin via a catheter; after confirming that the ACT was ≥200 s 10 min later, continuous heparin administration (50 units/kg/h) was started. After 24 h, an endoscope was inserted under general anesthesia to evaluate the blood volume in the stomach and the degree of blood adherence at the site of the mucosal defect. Results: Delayed bleeding was observed in three swine (75%) in the heparin-treated group, who had a maximum ACT of >220 s before the start of continuous heparin administration. In the non-treated group (n = 3), no prolonged ACT or delayed bleeding was observed at 24 h. Conclusion: An animal model of delayed bleeding after an endoscopic procedure in the gastrointestinal tract was established using a single dose of heparin and continuous heparin administration after confirming an ACT of 220 s.

Acquired factor XIII deficiency presenting with multiple intracranial hemorrhages and right hip hematoma: A case report.

BACKGROUND: Factor XIII (FXIII) deficiency is a rare yet profound coagulopathy. FXIII plays a pivotal role in hemostasis, and deficiencies in this factor can precipitate unchecked or spontaneous hemorrhaging. Immunological assays for detecting FXIII inhibitors are indispensable for diagnosing acquired FXIII deficiency; however, the availability of suitable testing facilities is limited, resulting in prolonged turnaround times for these assays. CASE SUMMARY: In this case study, a 53-year-old male devoid of significant medical history presented with recurrent intracranial hemorrhages and a hematoma in the right hip. Subsequent genetic analysis revealed a homozygous mutation in the ACE gene, confirming the diagnosis of acquired FXIII deficiency. CONCLUSION: This case underscores the significance of considering acquired deficiencies in clotting factors when evaluating patients with unexplained bleeding episodes.

Asymptomatic Portal Vein Aneurysm Uncovered During the Evaluation of a Gastrointestinal Hemorrhage: A Rare Clinical Case.

Portal vein aneurysms (PVAs) are rare vascular anomalies that are most often discovered incidentally during imaging for unrelated conditions. Their management remains controversial due to the limited data available. Here, we report the case of a 72-year-old male who presented with gastrointestinal bleeding and was found to have an incidental 4.9 cm PVA on abdominal computed tomography angiography (CTA), managed conservatively with regular follow-up imaging and monitoring. PVAs, while rare, present a significant clinical challenge due to the lack of consensus on their management. Treatment strategies range from conservative monitoring to surgical intervention, depending on the presence of symptoms, aneurysm size, and underlying etiology. This case highlights the importance of a multidisciplinary approach in managing PVAs, particularly when they are discovered incidentally. Further research is needed to develop standardized guidelines that address the nuances of treating both congenital and acquired PVAs.

Prognosis of major bleeding based on residual variables and machine learning for critical patients with upper gastrointestinal bleeding: A multicenter study.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a significant cause of morbidity and mortality worldwide. This study investigates the use of residual variables and machine learning (ML) models for predicting major bleeding in patients with severe UGIB after their first intensive care unit (ICU) admission. METHODS: The Medical Information Mart for Intensive Care IV and eICU databases were used. Conventional ML and long short-term memory models were constructed using pre-ICU and ICU admission day data to predict the recurrence of major gastrointestinal bleeding. In the models, residual data were utilized by subtracting the normal range from the test result. The models included eight algorithms. Shapley additive explanations and saliency maps were used for feature interpretability. RESULTS: Twenty-five ML models were developed using data from 2604 patients. The light gradient-boosting machine algorithm model using pre-ICU admission residual data outperformed other models that used test results directly, with an AUC of 0.96. The key factors included aspartate aminotransferase, blood urea nitrogen, albumin, length of ICU admission, and respiratory rate. CONCLUSIONS: ML models using residuals improved the accuracy and interpretability in predicting major bleeding during ICU admission in patients with UGIB. These interpretable features may facilitate the early identification and management of high-risk patients, thereby improving hemodynamic stability and outcomes.

One-month DAPT after biodegradable-polymer everolimus-eluting stent implantation in women at high-bleeding risk: Insights from the POEM trial.

AIMS: We conducted a prespecified subanalysis of the POEM trial to assess the association between sex and clinical outcomes following a short 1-month dual-antiplatelet-therapy (DAPT) period after percutaneous coronary intervention (PCI) with bioresorbable polymer everolimus-eluting stent (BP-EES) among patients at high bleeding risk (HBR). BACKGROUND: Shortening the DAPT period after PCI is an effective bleeding avoidance strategy with contemporary drug-eluting stents. Whether sex affects the risk of adverse events following PCI is still debated. METHODS: Patients at HBR undergoing PCI with BP-EES were enrolled and treated with 1-month DAPT. If anticoagulation was needed, study participants received an oral anticoagulant (OAC) in addition to a P2Y12 inhibitor for 1 month, followed by OAC only thereafter. The primary endpoint was a composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis at 12 months. We report sex-based outcomes of patients included in the POEM study. RESULTS: We enrolled 129 (29.1%) women and 314 (70.9%) men. Women were older, with lower hemoglobin levels, and worse renal function. Accordingly, they had a trend for a greater number of HBR criteria fulfilled and a higher PARIS bleeding score. However, they were not at a significantly higher risk for the primary endpoint (men vs. women: 5.17% vs. 3.94%; HR 1.30; 95% CI: 0.48-3.54, p = 0.61), or any of the hemorrhagic and ischemic secondary endpoints. CONCLUSIONS: This prespecified subanalysis of the POEM trial suggests that 1-month DAPT following PCI with BP-EES may be a safe and effective therapeutic strategy for women at HBR.

Gastrointestinal bleeding following traumatic brain injury: A clinical study on predisposing factors and outcomes.

Background: Traumatic brain injury (TBI) is one of the most common causes of death and disability worldwide. Stress ulcers are common in critically ill patients and can lead to life-threatening gastrointestinal bleeding (GIB). This study investigates the impact of predisposing factors on GIB and outcomes of TBI patients. Methods: This retrospective cohort study included TBI patients admitted between February 2019 and November 2021. Patients' demographic information and clinical characteristics were collected and divided into Post-TBI GIB and No-GIB groups. During clinical follow-up, the Glasgow Outcome Score (GOS) and mortality were assessed. The correlation between predisposing factors and GIB was investigated. Results: Out of 164 eligible patients, 66.5% were males, and the mean age was 31.38 ± 13.44 years. There was a higher rate of severe TBIs (p<0.001), intra-axial lesions (P=0.014), hypotension at admission (p<0.001), and concurrent coagulopathies (p<0.001) in the Post-TBI GIB group compared to the No-GIB group. In contrast, the Glasgow Coma Scale (GCS) level upon admission and discharge (p<0.001) and serum hemoglobin level at admission (p<0.001) were lower in the Post-TBI GIB group than in the other group. Moreover, primary GCS (P=0.017) and hypotension at admission (P=0.009), spinal injury (P=0.028), and intra-axial brain injury (P=0.018) were independently associated with GIB in TBI patients. Conclusion: Primary GCS and hypotension at admission, spinal injury, and intra-axial brain injury are independent predictors for GIB in TBI patients. The presence of GIB in TBI patients is associated with worse neurological outcomes as assessed by GOS at approximately 18 months.

A comparative study of the local effect of tranexamic acid and phenylephrine on the amount of bleeding in rhinoplasty: A randomized clinical trial.

Background: Bleeding during nose surgery is very important, because it can cause a problem in the surgeon's field of view and lead to an increase in the probability of surgical complications. The aim of this study was to compare the local effects of tranexamic acid and phenylephrine on bleeding in rhinoplasty. Methods: The present study is a double-blind clinical trial in which 98 patients who were candidates for rhinoplasty Shiraz were randomly divided into 49 groups of phenylephrine and tranexamic acid. In the first group, 1 cc of phenylephrine and in the second group, 1 cc of tranexamic acid was used locally and then the variables in the two groups were compared. The current study was approved by the Iranian Clinical Trial Registration Center with code IRCT20201205049602N1. Results: The average blood pressure and heart rate in the phenylephrine group first increased and then decreased, but in the tranexamic acid group decreased from the beginning to 30 minutes. Based on the results of the test, there was a difference between the two groups in terms of the amount of bleeding, and a statistically significant relationship was observed. The average bleeding volume was lower in the phenylephrine group (p<0.0001). Conclusion: Results of this study showed that the amount of bleeding in the phenylephrine group was lower than that of tranexamic acid. It is recommended to use phenylephrine in rhinoplasty surgery to reduce bleeding and improve the surgeon's vision.

A comparative study of the clinical benefits of rivaroxaban and dabigatran in patients with nonvalvular atrial fibrillation with high bleeding risk.

Objective: Rivaroxaban and dabigatran are approved to reduce the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). However, the clinical benefits of rivaroxaban and dabigatran in people with high bleeding risk are unclear. Methods: A retrospective study was conducted on NVAF patients admitted to the First Affiliated Hospital of Zhengzhou University from May 31, 2016 to May 31, 2019. These patients had a high risk of bleeding and were taking at least one study medication. The aim of the study was to evaluate clinical benefits by comparing the efficacy and safety risks of these two medications. Results: A total of 1,301 patients with high bleeding risk were enrolled, including 787 patients in the rivaroxaban group and 514 patients in the dabigatran group. Results of the primary efficacy benefit endpoint were obtained from 104 patients (13.21%) in the rivaroxaban group and 81 (15.76%) patients in the dabigatran group [hazard ratio (HR): 0.860; 95% confidence interval (CI): 0.637-1.162; P = 0.327], this indicates that there was no significant difference between dabigatran and rivaroxaban in preventing stroke and systemic embolism in patients with high bleeding risk NVAF. The principal safety end points were observed in 49 (6.23%) patients in the rivaroxaban group and in 36 (7.00%) patients in the dabigatran group (HR: 0.801 in the rivaroxaban group; 95% CI: 0.512-1.255; P = 0.333), this indicates that there was no a significant difference in reducing fatal bleeding and critical organ bleeding. With respect to secondary efficacy and benefit endpoints, 28 (3.56%) patients in the rivaroxaban group and 26 (5.06%) patients in the dabigatran group died, with an HR of 0.725 (95% CI: 0.425-1.238; P = 0.239); 32 (4.07%) patients in the rivaroxaban group; and 31 (6.03%) patients in the dabigatran group had myocardial infarction (MI), with an HR of 0.668 (95% CI: 0.405-1.102, P = 0.114) in the rivaroxaban group, this indicates that there was no significant difference between dabigatran and rivaroxaban in preventing all-cause death and MI. Conclusions: In NVAF patients with high bleeding risk, there was no significant difference between dabigatran and rivaroxaban in preventing stroke and systemic embolism. There was also no significant difference between dabigatran and rivaroxaban in reducing fatal and critical organ bleeding. Clinical Trial Registration: Chinese Clinical Trials Registry, identifier ChiCTR2100052454.

Outcomes and complications of percutaneous nephrolithotomy as primary versus secondary procedure for kidney stones: a prospective cohort study.

Introduction: Currently, percutaneous nephrolithotomy (PCNL) is the gold standard of treatment for large renal stones. The high prevalence of urolithiasis is associated with a high recurrence rate increasing the risk of re-intervention. This study aimed to compare the effectiveness and complications of PCNL among patients with previous therapeutic interventions for renal stones. Methods: Between August 2018 and September 2023, 245 patients were prospectively enrolled in this study and who underwent PCNL for renal stones at our institution. We compared patients who had no previous renal surgery (group 1: n=171) with those who had a history of open renal surgery (group 2: n=45) or previous PCNL on the ipsilateral kidney (group 3: n=31). All patients underwent surgery in the Galdakao-modified Valdivia position. Data on stone characteristics and perioperative and postoperative parameters were collected. Technical features, success rates and morbidity were analyzed and compared between the groups. Results: The fluoroscopy time was significantly longer in the group of patients with previous open surgery than in groups 1 and 3 (161.47±52.44, 223.05±33.29, 172.27±30.51 sec, P<0.001). Similarly, the operative time was longer in group 2 (138.20±38.86 min, P<0.001). The immediate stone-free rates in groups 1, 2, and 3 were 74.8%, 72.1%, and 77.4%, respectively (P=0.945). At 1-month, these rates increased to 98.8%, 96.2% and 96.8%, respectively (P=0.857). No difference was detected between the groups in terms of complication rate. The average Hb variation was 1.08±0.82, 1.34±1.01 and 0.94±0.69 g/dl for groups 1, 2 and 3, respectively(P=0.082). Hospital stay was longer in group 2 than in groups 1 and 3 (2.17±1.03, 2.53±1.22, 1.88±1.00 days, P=0.07), respectively. Conclusion: PCNL in patients with a history of renal surgery was associated with longer fluoroscopy and operative time. However, the success and morbidity rates as a secondary procedure were similar to those of PCNL in patients with no previous intervention.

Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding.

How to cite this article: Finsterer J. Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding. Indian J Crit Care Med 2024;28(9):890-891.

Factor Xa Inhibitors and Low Molecular Weight Heparins in Perioperative Surgical Thromboprophylaxis: A Network Meta-Analysis.

BACKGROUND: venous thromboembolism (VTE) prophylaxis is crucial for reducing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). This network metaanalysis was carried out to determine the most effective intervention among selective Xa inhibitors and low molecular weight heparins (LMWHs) for perioperative surgical thromboprophylaxis in major abdominal, pelvic, lumbar spine, and lower limb surgeries. METHODS: A systematic literature search was conducted for randomized controlled trials (RCTs) comparing selective factor Xa inhibitors, LMWHs, and placebo as thromboprophylaxis agents in major abdominal, pelvic, lumbar spine, and lower limb surgeries. A Bayesian network metaanalysis was performed to compare all interventions for the risk of developing DVT, VTE, major VTE, total bleeding, and major bleeding. The surface under the cumulative ranking curves was used to rank all interventions. RESULTS: Of 1788 retrieved references, 42 RCTs comparing 11 anticoagulants were included. As compared to enoxaparin, the risk of DVT was significantly reduced in patients treated with fondaparinux [RR: 0.53 (95% CrI: 0.31, 0.93)] and rivaroxaban [RR: 0.42 (95% CrI: 0.27, 0.64)]; VTE in patients treated with bemiparin [RR: 0.09 (95% CrI: 0, 0.7)], edoxaban [RR: 0.43 (95% CrI: 0.18, 0.96)], fondaparinux [RR: 0.55 (95% CrI: 0.34, 0.91)] and rivaroxaban [RR: 0.56 (95% CrI: 0.34, 0.85)]; major VTE in patients treated with rivaroxaban [RR: 0.26 (95% CrI: 0.11, 0.6)]. According to the surface under the cumulative ranking curves (SUCRA) value, fondaparinux and bemiparin increase the risk of serious bleeding more than other factor Xa inhibitors and LMWHs. CONCLUSION: Rivaroxaban, fondaparinux, edoxaban, and bemiparin are superior perioperative thromboprophylaxis agents than enoxaparin in major surgeries. Fondaparinux and bemiparin have shown the highest risk of major bleeding compared to other factor Xa inhibitors and LMWHs.

Abnormal uterine bleeding and its causes. Literature review.

Based on the analysis of information from available sources of scientific literature, the article provides an overview of the problem of abnormal uterine bleeding and its causes. Preservation of women's reproductive health is an urgent problem of the whole world. AUB is a debilitating symptom that affects a large number of women and one of the most common gynecological abnormalities. АUB, as a rule, does not threaten a woman's life, but significantly decreases its quality. Menstrual disorders affect all aspects of a woman's life, even increasing the risk of premature death. Women with AUB are more likely to seek medical care due to social and physical factors, while 50% of female patients have mental health problems due to anxiety and depression. Structural causes of uterine bleeding increase as a woman ages, which can affect reproductive health. Extragenital disorders are considered one of the most frequent causes of AUB. This is explained by the features of the endometrium, the state of which is influenced by general changes in a woman's hormonal status and the functional state of some organs and systems. AUB can be caused by diseases of the thyroid gland, uncorrected diabetes, obesity, blood coagulation disorders (most often von Willebrand's disease), infectious diseases, certain drugs (corticosteroids, antipsychotic or antiepileptic drugs), climate change and diet, psychological stress, etc. Management of patients with abnormal uterine bleeding is a complex problem that should include assessment of gynecological status and consultation of related specialists (endocrinologists, cardiologists, etc.).

The WeThrive App and Its Impact on Adolescents Who Menstruate: Qualitative Study.

BACKGROUND: Heavy menstrual bleeding (HMB) affects up to 37% of adolescents. Without recognition, HMB can lead to other medical conditions resulting in diminished health-related quality of life. WeThrive, a new mobile health (mHealth) app, implements the pictorial bleeding assessment chart to identify HMB, and the adolescent Menstrual Bleeding Questionnaire to measure the effects of HMB on adolescents' health-related quality of life. If HMB is identified, WeThrive will connect users to local clinics for further assessment of their menstrual bleeding with a health care provider. OBJECTIVE: This study aimed to describe adolescents' experiences using WeThrive app. METHODS: This qualitative study was approved by the local Research Ethics Board in Halifax, Nova Scotia, and informed consent was provided by all participants. Individual semistructured interviews were held via videoconference with adolescents younger than 18 years, who had at least 1 menstrual period and had used WeThrive at least once. Interview transcripts were thematically analyzed by 2 investigators (MP and NMN) independently, and the κ statistic was calculated to determine the strength of correlation in themes. RESULTS: Five adolescents (mean age 15.5, range 13-18 years), participated in the interviews. All participants stated that WeThrive helps them better understand their menstrual periods by predicting period onset, recognizing menstrual symptoms, and identifying HMB. Four themes were identified: (1) the importance of visual features and usability, (2) newly obtained knowledge using WeThrive, (3) feature use depends on menstrual health, and (4) trustworthiness. There was substantial agreement on the identified themes (κ=0.73). CONCLUSIONS: WeThrive is visually appealing, and trustworthy, and helps users better understand their menstrual periods, including identifying HMB. By identifying HMB early, WeThrive has the potential to improve the recognition of bleeding disorders and iron deficiency in adolescents. WeThrive is a useful tool to help adolescents better understand their menstrual periods.

Evaluation of Etiological Factors Associated With Abnormal Uterine Bleeding Among Teenage Girls in a Tertiary Care Center: A Cross-Sectional Study.

BACKGROUND: Abnormal uterine bleeding (AUB) refers to irregularities in the frequency, regularity, duration, and volume of menstrual cycles, impacting about one-third of women at some point in their lives, during menarche and perimenopausal periods. This study aims to evaluate the various causes of menstrual disorders in teenage girls. MATERIALS AND METHODS: This cross-sectional study was conducted in the Department of Obstetrics and Gynecology at AVMCH, Pondicherry, with ethical clearance. It included 150 girls aged 13-18 years who presented with menstrual disorders. Data were collected through structured interviews and clinical evaluations, focusing on menstrual history, socioeconomic status, associated symptoms, and investigations. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States). RESULTS: Among the etiological factors, 61.3% of patients had anovulatory dysfunction, 16.6% had early onset of PCOS, 6% of patients had hypothyroidism, 16% had ovulatory dysfunction, and 0.6% had coagulation disorder. Overall, ovulatory dysfunction (AUB-O) was predominant in teenage girls. CONCLUSION: This study helps in the early identification of the etiology of adolescent AUB and the appropriate management of menstrual disorders to improve well-being and enhance reproductive function in the future.

Terlipressin-induced skin necrosis in cirrhotic patients-A case report and comprehensive literature review.

Key Clinical Message: The occurrence of terlipressin-induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin-induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Abstract: Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin-induced skin necrosis. We present a 50-year-old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin-induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post-terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin-induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash.

Computed tomography-based multi-organ radiomics nomogram model for predicting the risk of esophagogastric variceal bleeding in cirrhosis.

BACKGROUND: Radiomics has been used in the diagnosis of cirrhosis and prediction of its associated complications. However, most current studies predict the risk of esophageal variceal bleeding (EVB) based on image features at a single level, which results in incomplete data. Few studies have explored the use of global multi-organ radiomics for non-invasive prediction of EVB secondary to cirrhosis. AIM: To develop a model based on clinical and multi-organ radiomic features to predict the risk of first-instance secondary EVB in patients with cirrhosis. METHODS: In this study, 208 patients with cirrhosis were retrospectively evaluated and randomly split into training (n = 145) and validation (n = 63) cohorts. Three areas were chosen as regions of interest for extraction of multi-organ radiomic features: The whole liver, whole spleen, and lower esophagus-gastric fundus region. In the training cohort, radiomic score (Rad-score) was created by screening radiomic features using the inter-observer and intra-observer correlation coefficients and the least absolute shrinkage and selection operator method. Independent clinical risk factors were selected using multivariate logistic regression analyses. The radiomic features and clinical risk variables were combined to create a new radiomics-clinical model (RC model). The established models were validated using the validation cohort. RESULTS: The RC model yielded the best predictive performance and accurately predicted the EVB risk of patients with cirrhosis. Ascites, portal vein thrombosis, and plasma prothrombin time were identified as independent clinical risk factors. The area under the receiver operating characteristic curve (AUC) values for the RC model, Rad-score (liver + spleen + esophagus), Rad-score (liver), Rad-score (spleen), Rad-score (esophagus), and clinical model in the training cohort were 0.951, 0.930, 0.801, 0.831, 0.864, and 0.727, respectively. The corresponding AUC values in the validation cohort were 0.930, 0.886, 0.763, 0.792, 0.857, and 0.692. CONCLUSION: In patients with cirrhosis, combined multi-organ radiomics and clinical model can be used to non-invasively predict the probability of the first secondary EVB.

Systematic treatment in gastric cancer patients with overt bleeding: A propensity score matching analysis.

BACKGROUND: Hemorrhage, which is not a rare complication in patients with gastric cancer (GC)/gastroesophageal junction cancer (GEJC), can lead to a poor prognosis. However, no study has examined the effectiveness and safety of chemotherapy as an initial therapy for GC/GEJC patients with overt bleeding (OB). AIM: To investigate the impact of OB on the survival and treatment-related adverse events (TRAEs) of GC/GEJC patients. METHODS: Patients with advanced or metastatic GC/GEJC who received systematic treatment at Peking University Third Hospital were enrolled in this study. Propensity score matching (PSM) analysis was performed. RESULTS: After 1:2 PSM analysis, 93 patients were assessed, including 32 patients with OB before treatment (OBBT) and 61 patients without OBBT. The disease control rate was 90.6% in the group with OBBT and 88.5% in the group without OBBT, and this difference was not statistically significant. There was no difference in the incidence of TRAEs between the group with OBBT and the group without OBBT. The median overall survival (mOS) was 15.2 months for patients with OBBT and 23.7 months for those without OBBT [hazard ratio (HR) = 1.101, 95% confidence interval (CI): 0.672-1.804, log rank P = 0.701]. The mOS was worse for patients with OB after treatment (OBAT) than for those without OBAT (11.4 months vs 23.7 months, HR = 1.787, 95%CI: 1.006-3.175, log rank P = 0.044). CONCLUSION: The mOS for GC/GEJC patients with OBBT was similar to that for those without OBBT, but the mOS for patients with OBAT was worse than that for those without OBAT.