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.

Gallbladder hemorrhage during orally administered edoxaban therapy: a case report.

BACKGROUND: Edoxaban is an orally administered anticoagulant treatment that is used in patients with cerebral infarction, venous thrombosis, or other conditions, with a reported incidence of gastrointestinal hemorrhage at approximately 1%. We encountered the rare case of a patient who developed a gallbladder hemorrhage after the administration of edoxaban. CASE PRESENTATION: An 86-year-old Japanese woman visited our gastrointestinal department due to the chief complaint of melena lasting for a week. Her medical history included hypertension and embolic cerebral infarction, and she was taking orally administered carvedilol (5 mg/day) and edoxaban (30 mg/day). Her palpebral conjunctiva was pale during a physical examination, indicating the possibility of anemia. Her blood test results confirmed severe anemia with red blood cells at 1.7 × 106/µL and hemoglobin at 4.7 g/dL. An upper gastrointestinal endoscopy revealed bile and fresh blood on the duodenal bulb and in more distal regions; hemobilia was suspected. A computed tomography scan on the ninth hospitalization day confirmed the hemobilia with a gallbladder fundus high-density signal. She was discharged on the 30th day of hospitalization with only fluid therapy and no progression of anemia. Moreover, she underwent a laparoscopic cholecystectomy 1 month after discharge, but the pathologist did not identify false aneurysms or neoplastic lesions. She has not been shown to develop anemia for 5 months after surgery. CONCLUSIONS: Our case suggests that gallbladder hemorrhage needs to be considered a possible complication for patients on direct oral anticoagulants.

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.

Eficacia de lanreótido en pacientes con angiodisplasias gastrointestinales refractarias al tratamiento con octreótido / Efficacy of lanreotide in patients with gastrointestinal angiodysplasia refractory to octreotide therapy

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Signs and symptoms indicative of potential adverse drug reactions in homecare patients.

PURPOSE: The purpose of this study was to determine whether homecare workers can detect signs and symptoms indicative of potential adverse drug reactions (ADRs) in homecare patients, using a standardized observation list. METHODS: This observational study involved 115 patients cared for by 2 homecare organizations in The Netherlands between April 2011 and August 2011. During routine home visits, homecare workers filled out a standardized observation list of signs and symptoms indicative of potential ADRs, namely, gastrointestinal and other bleedings, electrolyte disturbances, renal and heart failure, digoxin intoxication, constipation, disturbances of diabetic control, and falls. Their observations were compared against the medications that the patients were using and their known side effects, by a panel of clinical pharmacology experts. Sensitivity, specificity, and positive and negative predicted values of the standardized observations were calculated. RESULTS: In total, 234 signs and symptoms indicative of potential ADRs were observed by the homecare workers, 116 (49.6%) of which were considered drug related. More than one-half of the observed signs of gastrointestinal bleeding could be considered as drug related. Observed dizziness (64.1%) and drowsiness (53.3%) could be drug related in most cases, as could most cases (71.4%) of fainting spells (indicative of renal or heart failure). Seventeen of 20 observed falls could be drug related. The specificity of the standardized observation list was high, varying from 0.70 (confidence interval 0.62-0.77) to 0.97 (confidence interval 0.95-0.98). CONCLUSIONS: Signs and symptoms indicative of potential ADRs recorded by homecare workers using a standardized observation list can aid in the early recognition of ADRs in homecare patients.

Formic acid poisoning in a tertiary care center in South India: A 2-year retrospective analysis of clinical profile and predictors of mortality.

BACKGROUND: Formic acid (FA), a common industrial compound, is used in the coagulation of rubber latex in Kerala, a state in southwestern India. Easy accessibility to FA in this region makes it available to be used for deliberate self-harm. However, the literature on intentional poisoning with FA is limited. STUDY OBJECTIVES: To determine the patterns of presentation of patients with intentional ingestion of FA and to find the predictors of mortality. A secondary objective was to find the prevalence and predictors of long-term sequelae related to the event. METHODS: We performed a 2-year chart review of patients with acute intentional ingestion of FA. Symptoms, signs, outcomes and complications were recorded, and patients who survived the attempt were followed-up by telephone or personal interview to identify any complications after their discharge from the hospital. RESULTS: A total of 302 patients with acute formic acid ingestion were identified during the study period. The mortality rate was 35.4% (n = 107). Bowel perforation (n = 39), shock (n = 73), and tracheoesophageal fistula (n = 4) were associated with 100% mortality. Quantity of FA consumed (p < 0.001), consuming undiluted FA (p < 0.001), presenting symptoms of hypotension (p < 0.001), respiratory distress (p < 0.001), severe degree of burns (p = 0.020), hematemesis (p = 0.024), complications like metabolic acidosis (p < 0.001) and acute respiratory distress syndrome (p < 0.001) were found to have significant association with mortality. The prevalence of esophageal stricture (n = 98) was 50.2% among survivors and was the most common long-term sequela among the survivors. Stricture was significantly associated with hematemesis (p < 0.001) and melena (p < 0.001). CONCLUSION: This study highlights the magnitude and ill-effects of self-harm caused by a strong corrosive, readily available due to very few restrictions in its distribution. Easy availability of FA needs to be curtailed by enforcing statutory limitations in this part of the world. Patients with hematemesis or melena after FA ingestion may be referred for early dilatation therapy in a setting where emergency endoscopic evaluation of all injured patients is not practical.

Upper gastrointestinal haemorrhage in the acute cardiac care setting: antiplatelets and endoscopy.

Upper gastrointestinal haemorrhage (UGIH) in cardiac patients receiving antiplatelets presents a difficult management problem. The aim of this study was to describe a series of cardiac inpatients receiving antiplatelets who underwent endoscopy for an acute UGIH. Cardiac inpatients receiving antiplatelets and requiring endoscopy for UGIH over an 18-month period were followed up. Forty-one patients were studied. Most patients (25 [61%]) presented with melaena. Antiplatelets were withheld in 34 (83%) patients; predominantly in those with higher pre-endoscopy Rockall scores (median, 4; interquartile range [IQR], 3-5 versus median, 3; IQR, 2-4; P < 0.05). Positive findings were identified at endoscopy in 80%. Duodenal ulcers were the most common lesion and adrenaline the most common method of haemostasis. Median time to first endoscopy was 0 (IQR, 0-1) days. Seven (17%) patients re-bled, median Rockall score was six (IQR, 4-8). Three (7%) patients experienced procedural complications, two patients became hypoxic and one patient died. Following endoscopy, antiplatelets were restarted after a median of three (IQR, 3-5) days. On discharge, 27/28 (96%) patients continued with antiplatelet and proton-pump inhibitor therapy. Thirty-day inpatient mortality was 7% (3 patients). One patient re-bled within six months of discharge. Endoscopy helped assess the risk of re-bleeding and timing of antiplatelet re-introduction in cardiac inpatients experiencing UGIH.

Pretreatment with anti-VEGF therapy may exacerbate inflammation in experimental acute colitis.

AIM: Our previous investigations of angiogenesis in inflammatory bowel disease showed that vascular endothelial growth factor (VEGF) blockade reduced colonic neovascularization and inflammation. We hypothesized that pretreatment with bevacizumab, a monoclonal anti-VEGF antibody, would attenuate the severity of angiogenesis and inflammation in a murine model of colitis. METHODS: C57BL/6 mice were treated with intraperitoneal injections of bevacizumab (250 µg/dose) before induction of colitis with dextran sulfate sodium (DSS). The colons were examined at predetermined time points. Colonic inflammation and microvessel density were assessed microscopically. RESULTS: All mice acutely developed melena and weight loss (18.8% ± 1.1% control vs 20.2% ± 1.1% treated, P = .37) and regained a similar weight percentage after the recovery (26.5% ± 4.0% vs 20.9% ± 4.4%, P = .37). Microvessel density acutely increased in both groups in response to DSS, with a trend toward inhibited angiogenesis in the treated group at the conclusion of the acute phase (194,100 ± 14,240 vs 149,400 ± 17,590 µm(2), P = .11). Bevacizumab-treated mice exhibited significantly increased inflammation after the acute phase (8.3 ± 0.8 vs 13.0 ± 2.0, P = .05), but were similar to control after the recovery (7.3 ± 1.5 vs 5.5 ± 1.0, P = .27). CONCLUSIONS: Preemptive VEGF inhibition does not significantly attenuate angiogenesis and, in fact, worsens inflammation in a model of acute colitis. Preventive VEGF blockade may disrupt healing and exacerbate injury via alternative angiogenic or inflammatory pathways.

Continuous proton pump inhibitor treatment decreases upper gastrointestinal bleeding and related death in rural area in Japan.

BACKGROUND AND AIMS: Proton pump inhibitors (PPI) have been rarely used for prevention of upper gastrointestinal bleeding (UGIB) induced by non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin in Japan. The increased incidence of UGIB in the aged society is becoming a serious problem. The aim of this study was to retrospectively evaluate whether PPI can prevent UGIB. METHODS: We examined records of 2367 patients (aged 67.9 ± 15.1 years, male 1271) attending the only hospital serving the rural area, with little population movement. We investigated the correlation between the frequency of usage of medicine (PPI, histamine 2 receptor antagonists [H2RA], NSAIDs, aspirin) and incidence of UGIB over 12 years. UGIB was defined as cases with hematemesis and/or melena and definite bleeding at upper gastrointestinal endoscopy. The annual incidence of UGIB of inhabitants (16,065 ± 375.3 persons/year) was evaluated. The frequency of usage of medicine was compared with the total number of patients prescribed any medication (1080 ± 33.2 persons/year). RESULTS: The frequency of PPI usage has increased significantly 4.6%→30.8% (P < 0.05). NSAIDs and aspirin usage increased significantly in the latter half of the survey period (P < 0.05). The annual incidence of UGIB significantly decreased 160.8 →23.6/100,000 inhabitants per annum (P ≤ 0.05) due to widespread use of PPI. No patients died due to UGIB after 2006. The incidence of UGIB and the prevalence of PPI usage were found to have a negative correlation (r = -0.804, P = 0.0016). CONCLUSIONS: By widespread use of PPI, UGIB and related death has declined significantly. This survey showed that continuous PPI treatment decreases UGIB and related death in community medicine.

Upper gastrointestinal bleeding in a patient receiving selective serotonin reuptake inhibitor.

An older woman presented to the hospital with abdominal pain and subsequently had three episodes of melaena, requiring blood transfusions. She was known to suffer with severe depression and was on high-dose fluoxetine. Gastroscopy and colonoscopy failed to reveal an underlying cause for gastrointestinal (GI) bleeding. Possibility of high-dose selective serotonin reuptake inhibitors causing GI bleed was raised. Fluoxetine was discontinued and the patient was commenced on mirtazapine. The patient had no further GI bleeding and had significant improvement in haemoglobin.

Coumarin-induced intramural hematoma of the duodenum: case report and review of the literature.

OBJECTIVE: Intramural hematoma of the small intestine is a complication of anticoagulant treatment with an estimated incidence of 1 case per 2500 anticoagulated patients per year. Patients may present with signs of small bowel obstruction or, in case of a ruptured hematoma, with upper gastrointestinal tract hemorrhage and hypovolemic shock. MATERIAL AND METHODS: Case report and review of the literature. RESULTS: We present a case of a 73-year-old male who was referred for a protruding mass in the duodenum and subsequently developed hematemesis and melena caused by a ruptured hematoma of the duodenal wall. CONCLUSIONS: Although intramural hematoma of the duodenum is a rare complication of anticoagulant therapy, early diagnosis with subsequent correction of coagulation parameters is of vital importance.

Antiplatelet therapy and percutaneous coronary intervention in patients with acute coronary syndrome and thrombocytopenia.

Platelets are crucial in the pathogenesis of acute coronary syndrome. Treatment for acute coronary syndrome usually involves antiplatelet, anticoagulant, and antithrombotic therapy, and the performance of percutaneous coronary intervention. All of the medications are associated with bleeding sequelae and are typically withheld from patients who have thrombocytopenia. The safety of antiplatelet therapy and percutaneous coronary intervention in patients who have acute coronary syndrome and thrombocytopenia is unknown, and there are no guidelines or randomized studies to suggest a treatment approach in such patients. Acute coronary syndrome is uncommon in patients who have thrombocytopenia; however, it occurs in up to 39% of patients who have both thrombocytopenia and cancer. Herein, we present the cases of 5 patients with acute coronary syndrome, thrombocytopenia, and cancer who underwent percutaneous coronary intervention with stenting. Before intervention, their platelet counts ranged from 17 to 72 x 10(9)/L. One patient underwent preprocedural platelet transfusion. All were given aspirin, alone or with clopidogrel. One patient experienced melena (of colonic origin). No other patient experienced bleeding sequelae. Aside from the occasional use of antiplatelet and thrombolytic agents in patients with thrombocytopenia, no therapeutic recommendation can be made until data are available on a larger patient population. Until then, treatment should conform to specific clinical circumstances. Approaches to the treatment of acute coronary syndrome in patients with thrombocytopenia might be better directed toward the evaluation of platelet function rather than toward absolute platelet count, and the risk-benefit equation of invasive procedures and antithrombotic therapies may need to incorporate this information.

Investigation of upper gastrointestinal bleeding after implantation of drug-eluting stents; prospective cohort study.

OBJECTIVE: After implantation of drug-eluting stents (DES), two or more anti-thrombotic agents are required. The risk of upper gastrointestinal bleeding (UGIB) in cases of DES implantation is thought to be significant. However, the incidence of UGIB has not yet been investigated in DES-implanted patients. This study aimed to investigate the incidence of UGIB after DES implantation and the awareness among cardiologists about this complication. MATERIAL AND METHODS: Subjects were 397 consecutive patients implanted with DES from August 2004 to September 2007 at two institutions. Endoscopic examinations were performed on DES-implanted patients who presented with hematemesis and/or tarry stools. The concomitant use of acid-suppressing agents was left to the cardiologists. In addition, 37 cardiologists were administered a questionnaire regarding UGIB after DES implantation. RESULTS: Low-dose aspirin and ticlopidine were prescribed in all patients. Forty-six patients had a past history of peptic ulcer. Acid-suppressing agents were concomitantly prescribed to 224 patients (56%) including 32 patients (70%) with a past history of peptic ulcer. UGIB due to gastric ulcers developed in 5 cases (1.3%). One case had received a half dose of H2-RA. No bleeding occurred in patients who received proton pump inhibitors (PPI). The incidence of UGIB was 4.0 per 1000 patient-years. The cardiologists who were surveyed recognized the risk of UGIB after DES implantation and the necessity for its prevention. However, they indicated that adequate management for preventing this complication has not been established. CONCLUSIONS: This study reassuringly demonstrated a low incidence of UGIB after DES implantation. Further study regarding the prophylaxis for UGIB after DES implantation is necessary.

High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study.

OBJECTIVE: Despite widespread use of colchicine, the evidence basis for oral colchicine therapy and dosing in acute gout remains limited. The aim of this trial was to compare low-dose colchicine (abbreviated at 1 hour) and high-dose colchicine (prolonged over 6 hours) with placebo in gout flare, using regimens producing comparable maximum plasma concentrations in healthy volunteers. METHODS: This multicenter, randomized, double-blind, placebo-controlled, parallel-group study compared self-administered low-dose colchicine (1.8 mg total over 1 hour) and high-dose colchicine (4.8 mg total over 6 hours) with placebo. The primary end point was > or = 50% pain reduction at 24 hours without rescue medication. RESULTS: There were 184 patients in the intent-to-treat analysis. Responders included 28 of 74 patients (37.8%) in the low-dose group, 17 of 52 patients (32.7%) in the high-dose group, and 9 of 58 patients (15.5%) in the placebo group (P = 0.005 and P = 0.034, respectively, versus placebo). Rescue medication was taken within the first 24 hours by 23 patients (31.1%) in the low-dose group (P = 0.027 versus placebo), 18 patients (34.6%) in the high-dose group (P = 0.103 versus placebo), and 29 patients (50.0%) in the placebo group. The low-dose group had an adverse event (AE) profile similar to that of the placebo group, with an odds ratio (OR) of 1.5 (95% confidence interval [95% CI] 0.7-3.2). High-dose colchicine was associated with significantly more diarrhea, vomiting, and other AEs compared with low-dose colchicine or placebo. With high-dose colchicine, 40 patients (76.9%) had diarrhea (OR 21.3 [95% CI 7.9-56.9]), 10 (19.2%) had severe diarrhea, and 9 (17.3%) had vomiting. With low-dose colchicine, 23.0% of the patients had diarrhea (OR 1.9 [95% CI 0.8-4.8]), none had severe diarrhea, and none had vomiting. CONCLUSION: Low-dose colchicine yielded both maximum plasma concentration and early gout flare efficacy comparable with that of high-dose colchicine, with a safety profile indistinguishable from that of placebo.

Cefdinir-associated "bloody stools" in an infant.

Cefdinir, a third-generation oral cephalosporin frequently used in pediatric populations, may cause red stools when administered with iron or products that contain iron, such as infant formula. This benign side effect is not well documented in the medical literature. We describe a 7-month-old girl who was evaluated for red stools while taking cefdinir along with an oral iron supplement.