A Study of Upper GI Endoscopic Findings in Patients Presented with Upper GI Bleed.

INTRODUCTION: Bleeding from upper gastrointestinal tract is approximately five times more common than bleeding from lower gastrointestinal tract. The most common cause has been gastroduodenal ulcer disease, Esophageal varices, Mallory-Weiss tear. MATERIALS: It is an observational study carried out in General medicine department in GSL hospital in patients presented with history of vomiting of frank blood and/or passed dark coloured stools were chosen for this study with an aim to find out the prevalence of nature of lesion on Upper Gastro Endoscopy in patients admitted for UGI bleed and to find out the prevalence of nature of lesion. RESULT: Detailed history regarding the UGI bleeding like number of times of hematemesis approximate quantity of blood vomited each time, associated with malena. Symptoms of common diseases that can lead to UGI bleeding and detailed history of drug intake like aspirin, other NSAIDs, steroids and symptoms due to blood loss were recorded in the questionnaire. CONCLUSION: The peptic ulcer disease was the most common lesion found on endoscopy with prevalence of 54% and Varices with prevalence of 16% Minor UGI bleed was the commonest presentation. Majority of lesions (60%) presented with minor UGI bleed 28% lesions presented as moderate UGI bleed. Only 8% presented as major UGI bleed. Varices account for the most common cause for major UGI bleed contributing 50%. Gastric ulcer was commonest lesions accounting for 37 cases (37%) among 72 cases having single acid peptic lesions on endoscopy. The second most common is common is duodenal ulcer (31%). References Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Diseases. 8th ed. Saunders: Philadelphia; 2006. pp. 1092-1096. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995;90(2):206-210.

Upper gastrointestinal bleeding in coronavirus disease 2019 patients.

PURPOSE OF REVIEW: Upper gastrointestinal bleeding (UGIB) has significant morbidity and UGIB cases have been described in coronavirus disease 2019 (COVID-19) patients. Management of this condition can be challenging considering both the possible severe COVID-19-related pneumonia as well as the risk of the virus spreading from patients to health operators. The aim of this paper is to review the most recent studies available in the literature in order to evaluate the actual incidence of UGIB, its clinical and endoscopic manifestations and its optimal management. RECENT FINDINGS: UGIB has an incidence between 0.5% and 1.9% among COVID-19 patients, and it typically presents with melena or hematemesis. Peptic ulcers are the most common endoscopic findings. High Charlson Comorbidity Index (CCI), dialysis, acute kidney injury and advanced oncological disease increase the risk for UGIB. Although anticoagulants are commonly used in COVID-19 patients they are not associated with an increased incidence of UGIB. Conservative management is a common approach that results in similar outcomes compared to upper GI endoscopic treatment. Apparently, UGIB in COVID-19 seems not have a detrimental effect and only one study showed an increased mortality in those who developed UGIB during hospitalization. SUMMARY: Incidence of UGIB in COVID-19 patients is similar to that of the general population. Despite the widespread use of anticoagulants in these patients, they are not associated with an increased risk of UGIB. Conservative management could be an effective option, especially for patients that are at risk of intubation.

Gastroenterology manifestations and COVID-19 outcomes: A meta-analysis of 25,252 cohorts among the first and second waves.

A meta-analysis was performed to identify patients with coronavirus disease 2019 (COVID-19) presenting with gastrointestinal (GI) symptoms during the first and second pandemic waves and investigate their association with the disease outcomes. A systematic search in PubMed, Scopus, Web of Science, ScienceDirect, and EMBASE was performed up to July 25, 2020. The pooled prevalence of the GI presentations was estimated using the random-effects model. Pairwise comparison for the outcomes was performed according to the GI manifestations' presentation and the pandemic wave of infection. Data were reported as relative risk (RR), or odds ratio and 95% confidence interval. Of 125 articles with 25,252 patients, 20.3% presented with GI manifestations. Anorexia (19.9%), dysgeusia/ageusia (15.4%), diarrhea (13.2%), nausea (10.3%), and hematemesis (9.1%) were the most common. About 26.7% had confirmed positive fecal RNA, with persistent viral shedding for an average time of 19.2 days before being negative. Patients presenting with GI symptoms on admission showed a higher risk of complications, including acute respiratory distress syndrome (RR = 8.16), acute cardiac injury (RR = 5.36), and acute kidney injury (RR = 5.52), intensive care unit (ICU) admission (RR = 2.56), and mortality (RR = 2.01). Although not reach significant levels, subgroup-analysis revealed that affected cohorts in the first wave had a higher risk of being hospitalized, ventilated, ICU admitted, and expired. This meta-analysis suggests an association between GI symptoms in COVID-19 patients and unfavorable outcomes. The analysis also showed improved overall outcomes for COVID-19 patients during the second wave compared to the first wave of the outbreak.

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.

Is coffee ground vomiting important? Findings from a large bleeding unit database and outcomes at 30 days.

OBJECTIVES: 'Coffee ground' vomiting (CGV) has classically been considered a sign of upper gastrointestinal bleeding. There is a paucity of data concerning endoscopic findings and outcomes in patients presenting with CGV. The aim of this study was to analyze endoscopic yield and 30-day outcomes in CGV patients. METHODS: Analysis was performed over the period 1992-2005 and four groups were identified: CGV alone, hematemesis alone, melena alone, and hematemesis and melena. Endoscopic yield, requirement for blood transfusion, rebleeding, and mortality rate at 30 days were calculated and compared using logistic regression analysis. RESULTS: 6054 patients (mean age 61.3 years, 3538 male) were included in the study. The hematemesis group was younger compared with the other groups. Therefore, endoscopic yield was adjusted for age and sex. CGV was associated with a significantly lower risk of gastric ulcer, duodenal ulcer, varices, gastric cancer, esophageal cancer, and Mallory-Weiss tears compared with some or all of the other groups. CGV was associated with an increased risk of esophagitis and no source was found. CGV was associated with a lower rate of blood transfusion and rebleeding (all P < 0.0001) but 30-day mortality rates were similar. CGV was less likely to require endoscopic intervention compared with the other groups (all P < 0.001). CONCLUSIONS: CGV is associated with a lower endoscopic yield, requirement for blood transfusion, rebleeding rate, and potential for intervention compared to those with hematemesis, melena or both. Mortality rates are similar suggesting a nonbleeding cause and therefore questions the role of endoscopy in CGV.

Three cases of an unusual cause of haematemesis: black oesophagus.

Black oesophagus, also termed acute oesophageal necrosis or Gurvits syndrome, is an uncommon but well-characterised entity predominantly involving the lower oesophagus. Co-morbidity-such as diabetes mellitus, hypertension, chronic liver or kidney or pulmonary disease-predisposes to this condition. On endoscopy, it appears as a diffuse, circumferential, black discolouration. Though poorly understood, tissue hypoperfusion appears central to its pathogenesis. Tackling the underlying predisposing co-morbidity and supportive management are the mainstay of therapy. Despite early diagnosis and prompt treatment, the outcome may be unfavourable and is related to the underlying aetiology. We report a case series of three patients of acute oesophageal necrosis who presented to us with symptoms of acute upper gastrointestinal bleeding and improved with conservative management.

Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania. METHODS: This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality. RESULTS: During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32-64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3-4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7-29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8-22.8). CONCLUSIONS: In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis.

AIM: To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB. METHODS: Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30 days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated. RESULTS: The mean age was 43.5 ± 17.2 years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7 gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3 mg/dL (p = 0.004), serum bicarbonate ≤ 15.7 mEq/L (p = 0.001), systolic blood pressure < 90 mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value. CONCLUSION: Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.

Analysis of rebleeding in cases of an upper gastrointestinal bleed in a single center series

Background: upper gastrointestinal bleeding (UGIB) is one of the main causes of hospital admission in gastroenterology departments and is associated with a significant morbidity and mortality. Rebleeding after initial endoscopic therapy occurs in 10-20% of cases and therefore, there is a need to define predictive factors for rebleeding. Aim: the aim of our study was to analyze risk factors and outcomes in a population of patients who suffered a rebleed. Methods: five hundred and seven patients with gastrointestinal bleeding were included. Clinical and biochemical data, as well as procedures and outcome six months after admission, were all collected. Documented clinical outcome included in-hospital and six-month delayed mortality, rebleeding and six-month delayed hemorrhagic and cardiovascular events. Results: according to a logistic regression analysis, high creatinine levels were independent risk factors for rebleeding of non-variceal and variceal UGIB. In non-variceal UGIB, tachycardia was an independent risk factor, whereas albumin levels were an independent protective factor. Rebleeding was associated with in-hospital mortality (29.5% vs 5.5%; p < 0.0001). In contrast, rebleeding was not related to six-month delayed mortality or delayed cardiovascular and hemorrhagic events. Conclusions: tachycardia and high creatinine and albumin levels were independent factors associated with rebleeding, suggestive of a potential predictive role of these parameters. The incorporation of these variables into predictive scores may provide improved results for patients with UGIB. Further validation in prospective studies is required

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Clinical pattern and prevalence of upper gastrointestinal toxicity in patients abusing ketamine.

OBJECTIVE: Evaluations of upper gastrointestinal toxicity from ketamine abuse are uncommon. This study investigated the clinical pattern of upper gastrointestinal symptoms in patients inhaling ketamine. METHODS: In a cross-sectional study of 611 consecutive patients who were seeking treatment for ketamine uropathy in a tertiary hospital setting between August 2008 and June 2016, their clinical pattern of upper gastrointestinal symptoms was evaluated and compared with a control population of 804 non-users. RESULTS: A total of 168 (27.5%) patients abusing ketamine (mean age 26.3 years, 58.9% female) reported the presence of upper gastrointestinal symptoms. These symptoms were significantly more prevalent in patients inhaling ketamine than in those who were not (27.5% vs 5.2%, P < 0.001). Their mean duration of ketamine abuse before symptom presentation was 5.0 ± 3.1 years. The presenting symptoms included epigastric pain (n = 155, 25.4%), recurrent vomiting (n = 48, 7.9%), anemia (n = 36, 5.9%) and gastrointestinal bleeding (n = 20, 3.3%). Uropathy symptoms were preceded by upper gastrointestinal symptoms for 4.4 ± 3.0 years in 141 (83.9%) patients. Logistic regression showed that elder age (odds ratio [OR] 1.06, P = 0.04), active abuser status (OR 1.60, P = 0.04) and longer duration of ketamine abuse (OR 1.00, P = 0.04) were independent factors associated with upper gastrointestinal toxicity. CONCLUSIONS: Although epigastric symptoms are unusual in the young population, upper gastrointestinal toxicity was highly prevalent in those inhaling ketamine. Enquiries about ketamine abuse are recommended when assessing young patients with epigastric symptoms.

Risk factors for hematemesis in Hoima and Buliisa Districts, Western Uganda, September-October 2015.

INTRODUCTION: On 17 September 2015, Buliisa District Health Office reported multiple deaths due to haemorrhage to the Uganda Ministry of Health. We conducted an investigation to verify the existence of an outbreak and to identify the disease nature, mode of transmission and risk factors. METHODS: We defined a suspected case as onset of hematemesis between 1 June 2015 and 15 October 2015 in a resident of Hoima, Buliisa or neighbouring districts. We identified cases by reviewing medical records and actively searching in the community. We interviewed case-patients and health-care workers and performed descriptive epidemiology to generate hypotheses on possible exposures. In a case-control study we compared exposures between 21 cases and 81 controls, matched by age (± 10 years), sex and village of residence. We collected 22 biological specimens from 19 case-patients to test for Viral Haemorrhagic Fevers (VHF). We analysed the data using the Mantel-Haenszel method to account for the matched study design. RESULTS: We identified 56 cases with onset from June to October (attack rate 15/100,000 in Buliisa District and 5.2/100,000 in Hoima District). The age-specific attack rate was highest in persons aged 31-60 years (15/100,000 in Hoima and 47/100,000 in Buliisa); no persons below 15 years of age had the illness. In the case-control study, 42% (5/12) of cases vs. 0.0% (0/77) of controls had liver disease (ORM-H = ∞; 95%CI = 3.7-∞); 71% (10/14) of cases vs. 35% (28/81) of controls had ulcer disease (ORM-H = 13; 95% CI = 1.6-98); 27% (3/11) of cases vs. 14% (11/81) of controls used indomethacin prior to disease onset (ORM-H = 6.0; 95% CI = 1.0-36). None of the blood samples were positive for any of the VHFs. CONCLUSION: This reported cluster of hematemesis illness was due to predisposing conditions and use of Non-Steroidal Anti-inflammatory Drugs (NSAID). Health education should be conducted on the danger of NSAIDs misuse, especially in persons with pre-disposing conditions.

Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics.

BACKGROUND: The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. METHODS: In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. RESULTS: Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01-5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively. CONCLUSIONS: Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.

Upper gastrointestinal bleeding as a risk factor for dialysis and all-cause mortality: a cohort study of chronic kidney disease patients in Taiwan.

OBJECTIVE: Impaired renal function is associated with higher risk of upper gastrointestinal bleeding (UGIB) in patients with chronic kidney disease and not on dialysis (CKD-ND). It is unclear if UGIB increases risk of chronic dialysis. The aim of the study was to investigate risk of chronic dialysis in CKD-ND patients with UGIB. SETTING: All CKD-ND stage 3-5 patients of a CKD programme in one hospital between 2003 and 2009 were enrolled and prospectively followed until September 2012. PRIMARY AND SECONDARY OUTCOME MEASURES: Chronic dialysis (dialysis for more than 3 months) started and all-cause mortality. The risk of chronic dialysis was analysed using Cox proportional hazard regression with adjustments for age, gender and renal function, followed by competing-risks analysis. RESULTS: We analysed 3126 CKD-ND patients with a mean age of 65±14 years for 2.8 years. Of 3126 patients, 387 (12.4%) patients developed UGIB, 989 (31.6%) patients started chronic dialysis and 197 (6.3%) patients died. UGIB increased all-cause mortality (adjusted HR (aHR): 1.51, 95% CI 1.07 to 2.13) and the risk of chronic dialysis (aHR; 1.29, 95% CI 1.11 to 1.50). The subdistribution HR (SHR) of UGIB for chronic dialysis (competing event: all-cause mortality) was 1.37 (95% CI 1.15 to 1.64) in competing-risks analysis with adjustments for age, renal function, gender, diabetes, haemoglobin, albumin and urine protein/creatinine ratio. CONCLUSIONS: UGIB is associated with increased risk of chronic dialysis and all-cause mortality in patients with CKD-ND stages 3-5. This association is independent of age, gender, basal renal function, haemoglobin, albumin and urine protein levels.

Upper gastrointestinal bleeding in children from a hospital center of Northeast Romania.

BACKGROUND: The aim of this study was to investigate the common etiologies, clinical and biological patterns of upper gastrointestinal bleeding (UGIB) in children from a hospital center in Northeast Romania. METHODS: This seven-year retrospective study was performed from 2007 to 2013 in St. Mary Children's Emergency Hospital, Jassy, Romania and included all children who referred to our center with UGIB exteriorized by hematemesis or melena. Endoscopy was performed under conscious sedation/general anesthesia after the informed consent was obtained. RESULTS: One hundred and three patients aged 1-18 years were included in this study. There were 57 males and 46 females with male to female ratio 1.2:1; 43.69% presented with hematemesis, 31.07% had melena and 25.24% had both. The most common causes of UGIB were erosive gastritis (33.98%), followed by esophagitis (14.56%), duodenitis (11.65%), duodenal ulcer (10.68%), gastric ulcer (5.83%), esophageal varices (4.85%), Mallory-Weiss syndrome (1.94%); multiple etiologies counted for 16.50% cases. A certain bleeding source was found in 34.95% cases, a possible one in 39.81% of the patients; the source could not be ascertained in 25.24% of cases. Nonsteroidal anti-inflammatory drug (NSAID) consumption was documented in in 17.51% of patients. The incidence of H. pylori infection was 36.89%. CONCLUSIONS: The most common cause of of upper GI bleeding in our series was gastritis, followed by oesophagitis and duodenitis. Most of the patients presented with hematemesis; previous consumption of NSAIDs and H. pylori infection were associated with gastroduodenal ulceration and bleeding. Early endoscopy was associated with a higher detection rate of the bleeding source.

Prevalence, patterns, and factors associated with bleeding tendencies in dengue.

INTRODUCTION: The pattern of bleeding tendencies in dengue and its corellation with platelet count and other factors requires clarification. METHODOLOGY: A retrospective study on bleeding tendencies in adults with dengue and platelet counts of less than 100,000 per mm(3) was conducted. Factors associated with bleeding were analyzed. The study cohort were grouped as dengue with severe thrombocytopenia when platelet count was < 50,000/mm(3) and as dengue with moderate thrombocytopenia if platelet count was 50,000-100,000/mm(3) RESULTS: A total of 638 patients formed the study cohort. A 24.1% prevalence of bleeding tendencies was observed. Prior anti-platelet drug intake, platelet count of < 70,000/mm(3), international normalized ratio > 2.0, and partial thromboplastin time > 60 seconds were associated with bleeding. Esophagogastroduodenoscopy was found to identify structural gastroduodenal lesions when dengue was complicated by hematemesis or melena. CONCLUSIONS: The results of this study suggest that bleeding complications in dengue can occur at platelet counts of up to 70,000/mm(3), and that prior anti-platelet drug intake increases bleeding risk. Evaluation of hematemesis or melena in dengue with esophagogastroduodenoscopy is beneficial.

Clinical outcomes of nonvariceal upper gastrointestinal bleeding in Kosova.

BACKGROUND/AIMS: The aim was to determine the sociodemographic and etiologic factors, endoscopic accuracy, treatment efficiency and clinical outcome of patients with nonvariceal upper gastrointestinal system bleeding in Kosova. MATERIALS AND METHODS: We retrospectively evaluated patients who had applied to our Gastroenterology Department between January 2006 and December 2010. RESULTS: There were 460 eligible cases with mean age 56.85+16.18 years, while male /female ratio was 2.71/1. The greatest occurrence was at age group of 60-69 years (27.1 %). The most common clinical symptom was melena (62.6%). Comorbid diseases were present in 57, 6% of the patients. The percentage of patients using acetylsalicylic acid and /or other non-steroidal anti-inflammatory drugs was 43.7%. Five point two percent were using anticoagulants. Peptic ulcer was the main cause of bleeding (82.2%) and most of them were Forrest III (41.6%). Endoscopic treatment was performed in 90 patients, primary hemostasis was achieved in 96.7% while rebleeding developed in 10% of these patients. The average length of hospital stay was 9.29+5.58 (1-35) days. Rebleeding was reported in 4.1% of all patients while the overall mortality rate was 5.7%. CONCLUSION: Age over 60 years, previous history of gastrointestinal bleeding, treatment with anticoagulants, low hemoglobin values at presentation (<7 g/dL), hematemesis, Forrest class, localization of lesion of bleeding, comorbidities, tachycardia, transfusion requirement>2 unit, type of treatment and time of endoscopy were predictors of poor outcome in study present.

Relationship between continuous use of low-dose enteric-coated aspirin and gastrointestinal injuries in patients with gastrointestinal hemorrhage.

BACKGROUND/AIMS: Gastrointestinal disorders are important side effects of aspirin therapy, even if the low-dose enteric-coated form is administered. The aim of the current study was to present the upper and lower endoscopic features of patients with gastrointestinal hemorrhage using low-dose enteric-coated aspirin. MATERIALS AND METHODS: This prospective study was conducted among 633 consecutive patients with gastrointestinal hemorrhage who admitted to our tertiary referral hospital for endoscopy assessment. Patients were divided into two groups as low-dose aspirin users (n=168) and non-aspirin users (n=495). Aspirin users included those who were taking 80-100 mg of enteric-coated aspirin per day. RESULTS: Ulcer lesions were found in 78 patients in the aspirin user group and in 113 patients in the control group. Prevalence of duodenal ulcer was statistically similar between the two groups; however, gastric ulcer was seen more in the aspirin-user group. The use of low-dose aspirin could strongly predict gastric ulcers in the patients examined by endoscopy (p<0.001). Overall prevalence of peptic ulcer disease in those with confirmed Helicobacter pylori infection was significantly higher than in non-infected ones (p<0.001). The presence of this infection was strongly associated with peptic ulcer disease in the aspirin-user group (p<0.001). Multivariable analysis also demonstrated that the use of aspirin had a main triggering effect on short-term mortality following gastrointestinal endoscopy (p=0.003). CONCLUSIONS: Low-dose enteric-coated aspirin causes significant gastric endoscopic lesions and even predicts mortality due to progression of gastrointestinal disorders.

Nonvariceal upper gastrointestinal bleeding in Portugal: a multicentric retrospective study in twelve Portuguese hospitals.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with important mortality. More information is needed in order to improve NVUGIB management. The aims of this study were: (a) characterizing Portuguese patients and clinical approaches used in NVUGIB, (b) comparing management used in Portugal with management globally used in European countries, (c) identify factors associated with management options, and (d) identify factors associated with adverse outcome. METHODS: ENERGiB was an observational, retrospective cohort study, on NVUGIB with endoscopic evaluation, carried across Europe. This study focuses on Portuguese patients of the ENERGiB study. Patients were managed according to routine care. Later, data were collected from files. Multivariate/univariate analyses were conducted on predictive factors of poor outcome and clinical decisions. RESULTS: Patients (n=404) were mostly men (66.8%), mean age 68, with co-morbidities (72%), frequently on NSAIDs/aspirin. Most were assisted by general medical (57.8%) or surgical team (20.6%), only 19.4% by gastroenterology/GI-bleeding team. PPI was largely used. Gastric/duodenal ulcers, erosive gastritis and esophagitis were the main bleeding causes. 10% had bleeding persistence/recurrence. Death occurred in 24 patients, 20 from a non-bleeding related cause. Poor outcomes were related with age >65, co-morbidities, fresh blood haematemesis, shock/syncope, bleeding through previous nasogastric tube, massive fluid replacement or transfusions besides erythrocytes. CONCLUSIONS: This study contributed to characterization of Portuguese patients and NVUGIB episodes in real clinical setting and identified factors associated with a poor outcome. It also identified differences, especially in the organization of GI bleeding teams, which might help us to improve the management of these patients.

Predictors of clinically significant upper gastrointestinal hemorrhage among children with hematemesis.

OBJECTIVES: The aim of the study was to determine the proportion of children with hematemesis who experience a clinically significant upper gastrointestinal hemorrhage (UGIH) and to identify variables predicting their occurrence. METHODS: A retrospective cohort study was conducted. All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed. The primary aim of the study was to determine the proportion of children who developed a clinically significant UGIH; the secondary aim was to identify risk factors predictive of a clinically significant UGIH. A significant UGIH was defined by any of the following: hemoglobin drop >20 g/L, blood transfusion, or emergent endoscopy or surgical procedure. RESULTS: Twenty-seven of 613 eligible children (4%; 95% confidence interval 3%-6%) had a clinically significant UGIH. Clinically significant hemorrhages were associated with older age (9.7 vs 2.9 years; P<0.001), vomiting moderate to large amounts of fresh blood (58% vs 20%; P<0.001), melena (37% vs 5%; P<0.001), significant medical history (63% vs 24%; P<0.001), unwell appearance (44% vs 6%; P<0.001), and tachycardia (41% vs 10%; P<0.001). The frequency of laboratory investigations increased with age (P<0.001). The hemoglobin level was the only laboratory investigation whose results differed between those with and without significant bleeds. The presence of any one of the following characteristics identified all of the children with a clinically significant hemorrhage: melena, hematochezia, unwell appearance, or a moderate to large volume of fresh blood in the vomitus, sensitivity 100% (95% confidence interval 85%-100%). CONCLUSIONS: The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited a moderate to large amount of fresh blood.

Clinical outcomes following coronary stenting in Japanese patients treated with and without proton pump inhibitor.

BACKGROUND: The aim of this study was to examine the effect of proton-pump inhibitor (PPI) on clinical outcomes in Japanese patients who undergo coronary stent implantation. METHODS AND RESULTS: A total of 1,270 patients (males 915, 69 years) were enrolled and dual antiplatelet therapy of aspirin and a thienopyridine derivative was prescribed (clopidogrel 630, ticlopidine 640). Patients were divided into 2 groups treated with or without PPI. PPI was administered in 331 cases (26%), and non-PPI in 939 (74%). There were no significant differences in cardiovascular death (PPI vs. non-PPI: 5 vs. 11 cases), nonfatal myocardial infarction (3 vs. 5), and stroke (3 vs. 16) between PPI and non-PPI groups, but the ratio of gastrointestinal events had a higher tendency in non-PPI group compared with PPI group (1 vs. 17, P=0.08). In subgroup analysis of patients taking clopidogrel, or patients with acute coronary syndrome, there was no significant difference in the ratio of cardiovascular events (7 vs. 16, 6 vs. 17, NS). The non-PPI group had a tendency of an increased risk of gastrointestinal events compared with the PPI group (0 vs. 9, P=0.06; 1 vs. 7, P=0.14). CONCLUSIONS: In contrast to the negative drug interaction of PPI reported elsewhere, in the present study the intake of PPI was not associated with an increased risk for adverse clinical outcomes in patients treated with stents.