Prognosis of variceal and non-variceal upper gastrointestinal bleeding in already hospitalised patients: Results from a French prospective cohort.

OBJECTIVES: Patients who develop upper gastrointestinal bleeding (UGIB) while in hospital appear to have a poor prognosis. Our study aims at analysing the difference in outcome between in-patients (IPs) and out-patients presenting with variceal and non-variceal UGIB. METHODS: We conducted a multicentre prospective study by collecting data about variceal and non-variceal UGIB cases through 46 hospitals in France between November 2017 and October 2018. We then compared baseline demographic features, endoscopic findings and outcome between patients who developed variceal and non-variceal UGIB on admission (OPs) and those at least 24 h after hospitalisation (IPs). Our primary end-point was mortality and re-bleeding rates at 6 weeks of bleeding onset. RESULTS: A total of 2498 UGIB cases were identified, of whom 634 (25.4%) occurred in IPs. IPs were older than OPs (72.5 vs. 67.2 years old, p < 0.001) and had a higher rate of comorbidities (38.9% vs. 26.6%, p < 0.0001). Their bleeding was more severe with a Rockall score of >5 present in 40.9% (vs. 30.3% in OPs, p < 0.0001). The 6-week mortality rate was significantly higher in IPs when compared to OPs (21.7% vs. 8%, p < 0.0001). Prothrombin time <50% and rebleeding were the only independent predictors of mortality (p = 0.001 and 0.003, respectively). Six-week rebleeding occurred more frequently among IPs (18.6% vs. 14.4%, p = 0.015) and predictors included female sex, active bleeding upon endoscopy and a Blatchford score >11 (p = 0.017, 0.011 and 0.008, respectively). CONCLUSION: IPs who develop variceal and non-variceal UGIB are more likely to be elderly with more comorbidities. They have a higher rate of mortality and rebleeding. Independent predictors of mortality were underlying coagulopathy and bleeding recurrence. An optimal bleeding management and efficient rebleeding prevention may improve outcome in these patients.

Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding.

BACKGROUND: The diagnostic yield of push enteroscopy (PE) in patients with unexplained overt GI bleeding is about 30%. The aim of this study was to assess for predictive factors of positive findings. METHODS: A total of 182 patients referred to two endoscopic centers (European Georges Pompidou Hospital [Paris, France] and Erasmus Hospital [Brussels, Belgium]) for unexplained overt GI bleeding (melena [57%], hematochezia [26%], or hematochezia associated with melena [17%]) were included in this retrospective study. Predictive factors associated with positive findings at upper PE were studied by using uni- and multivariate analysis. RESULTS: The overall diagnostic yield of upper PE was 34% (62/182), but lesions were found beyond the second duodenum in 25% of the patients (45/182). Factors significantly associated with positive findings at upper PE were the following. (1) In univariate analysis: the presence of melena, Hb level <7 g/dL, blood transfusion >4 units per patient, chronic renal failure, disorder of hemostasis or effective anticoagulant treatment, history of intestinal arteriovenous malformation, and age > 65 years. (2) In multivariate analysis: chronic renal failure and presence of melena. If only jejunal lesions were considered, chronic renal failure was the only predictive factor associated with positive findings at upper PE in multivariate analysis. The severity of GI bleeding did not reach statistical significance ( p = 0.06). Delay between GI bleeding and PE, number of previous standard endoscopies and previous episodes of bleeding were not associated with positive findings in upper PE. CONCLUSIONS: In patients with unexplained overt GI bleeding, upper PE has a higher diagnostic yield in patients with chronic renal failure and patients with melena (vs. hematochezia).

Clinical impact of push enteroscopy in patients with gastrointestinal bleeding of unknown origin.

BACKGROUND & AIMS: Despite the frequent use of push enteroscopy (PE), little is known of its clinical impact. The aim of this study was to evaluate the impact of PE on diagnostic and therapeutic management of patients with gastrointestinal bleeding of unknown origin. METHODS: Seventy-five consecutive patients (mean age, 56 y) referred for PE were included in this 1-year prospective study. Indications for PE were overt bleeding in 46 patients (61%) and iron-deficiency anemia in 29 patients (39%). Before the procedure, the prescribing physicians were asked to fill out a questionnaire listing the theoretical patient management plan (diagnostic procedures and/or treatment) as if PE were not available. One month after PE, the same physicians were asked about: (1) diagnostic procedures performed after PE, (2) the final diagnosis, and (3) their opinion of the usefulness of PE in clinical management. The clinical impact of PE on diagnostic and/or therapeutic management was assessed by 3 study physicians. RESULTS: Responses to the 2 questionnaires were obtained for all patients. The diagnostic yield of PE was 32% (24 of 75). The clinical impact of PE (changes in diagnostic and/or therapeutic management) was 55% (n = 41). PE was perceived as helpful by the prescribing physicians in 55% of cases. PE tended to influence patient management more in cases of overt bleeding than in cases of occult bleeding (63% vs. 41%; P = 0.06). CONCLUSIONS: PE influenced the clinical management of more than half the patients with GI bleeding of unknown origin, and was particularly useful in patients with overt bleeding.