Red Blood Cell Distribution Width as a Risk Factor for 30/90-Day Mortality in Patients with Gastrointestinal Bleeding: Analysis of the MIMIC-IV Database.

PURPOSE: The purpose of this research was to assess the relationship between red blood cell distribution width (RDW) and mortality in patients with gastrointestinal (GIB) bleeding in the intensive care unit (ICU). METHODS: The information of the participants was obtained from the Medical Information Mart for Intensive Care IV database. The main outcome of this research was 30/90-day mortality, with ICU mortality and in-hospital mortality as secondary outcomes. RESULTS: This research included 2924 patients with gastrointestinal bleeding in total. Patients with higher RDW had considerably higher 30/90-day and in-hospital mortality rates, as well as longer hospital stays and ICU stays. According to the Kaplan-Meier analysis, the 30/90-day mortality rate was remarkably higher among participants in the higher RDW group (P < 0.0001). In the adjusted multivariate Cox regression analysis, for 30-day mortality, the HR (95% CI) was 1.75 (1.37, 2.24) in comparison to Q1 in the reference group (P < 0.001). Analyses of 90-day mortality and in-hospital mortality both showed the same results. In the subgroup analysis, gender, myocardial infarction, chronic pulmonary disease, cerebrovascular disease and renal disease had no significant effect on the correlation between RDW values and mortality (all P > 0.05). The area under the ROC curve for RDW was 0.599 (95% CI 0.581-0.617) and 0.606 (95% CI 0.588-0.624) in 30/90-day ICU mortality. CONCLUSION: The current research showed that RDW could be utilized as an independent indicator of short-term mortality in critically ill GIB patients at 30 and 90 days of hospital admission.

Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding.

BACKGROUND & AIMS: Acute kidney injury (AKI) is conventionally evaluated by a dynamic change of serum creatinine (Scr). Cystatin C (CysC) seems to be a more accurate biomarker for assessing kidney function. This retrospective multicenter study aims to evaluate whether AKI re-defined by CysC can predict the in-hospital outcomes of patients with liver cirrhosis and acute gastrointestinal bleeding. METHODS: Overall, 677 cirrhotic patients with acute gastrointestinal bleeding, in whom both Scr and CysC levels were detected at admissions, were screened. eGFRScr, eGFRCysC, and eGFRScr-CysC were calculated. MELD-Na score and AKI were re-evaluated by CysC instead of Scr. Odds ratios (ORs) were calculated in the logistic regression analyses. The receiver operating characteristic (ROC) curve analyses were performed. RESULTS: Univariate logistic regression analyses demonstrated that baseline Scr and CysC levels, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, MELD-Na score re-defined by CysC, and AKI re-defined by CysC, but not conventional AKI defined by Scr, were significantly associated with in-hospital death. ROC analyses showed that baseline CysC level, eGFRScr, eGFRCysC, eGFRScr-CysC, original MELD-Na score defined by Scr, and MELD-Na score re-defined by CysC, but not baseline Scr level, could significantly predict the risk of in-hospital death. CONCLUSIONS: AKI re-defined by CysC may be superior for predicting the in-hospital mortality of cirrhotic patients with acute gastrointestinal bleeding.

Post-transfusion hemoglobin response in patients with cirrhosis: Can we expect a 1 g/dL rise per unit transfused?

BACKGROUND: A patient's hemoglobin is typically expected to rise by 1 g/dL/unit transfused PRBCs. However, it has been theorized that mechanisms such as hyperbilirubinemia and splenomegaly might lead to either a direct lysis or sequestration of red blood cells that could decrease this proportionate response. STUDY DESIGN AND METHODS: Patients with resolved GI bleeding but still requiring transfusion to correct anemia were compared in cirrhosis and control groups. A retrospective chart review between 2015 and 2020 was conducted at a single institution. Data collected included age, sex, BMI, GI bleed diagnosis, number of PRBCs transfused, presence of splenomegaly and spleen size, alcohol use history, type of cirrhosis, MELD-Na at admission, GFR, and pre-and post-transfusion labs: total bilirubin, ALT, hemoglobin, hematocrit. A logic regression was performed for each group looking at which factors were associated with a successful response (defined as >0.9 g/dL hemoglobin per unit transfused). RESULTS: Mean change in hemoglobin was 0.77 g/dL in patients with cirrhosis compared to 1.46 g/dL in patients without (P < .001, N = 103). Odds ratios for presence of splenomegaly (0.22, N = 78) and female sex (4.39, N = 102) in predicting adequate response (>0.9 g/dL/unit) were both significant (P = .002) as well as portal hypertensive bleed diagnosis (0.28, N = 85, P = .0015). Factors that did not contribute included: age, race, BMI, alcohol use, GFR, change in ALT, and change in total bilirubin. CONCLUSIONS: Patients with cirrhosis have an approximately 50% decreased response to transfusion with PRBCs after resolution of a gastrointestinal bleed in comparison to patients without cirrhosis. Risk factors included splenomegaly, portal hypertension, and male sex.

Prealbumin and D-dimer as Prognostic Indicators for Rebleeding in Patients with Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND: Determining the risk stratification of nonvariceal upper gastrointestinal bleeding (NVUGIB) plays a vital role in treating upper gastrointestinal bleeding (UGIB). Traditional scores like Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score have been widely utilized in UGIB practice, however exhibiting limited practical use due to relative lack of user-friendly characters. Prealbumin as a nutritional indicator and d-dimer as a fibrinolytic activity monitor, are generally used to evaluate the overall nutritional and fibrinolytic condition in UGIB patients. AIMS: Here, we explored the predictive value of these two markers in NVUGIB for evaluating severity and prognosis including rebleeding and surgery intervention. METHODS: One hundred and eighty-five patients suffering NVUGIB were enrolled. Their GBS, RS, and AIMS65 score, routine laboratory test results including prealbumin and d-dimer were determined after admission. Multivariate regression analysis was performed to define the independent predictors of rebleeding. ROC curves were generated to compare the suitability of prealbumin, d-dimer, and scores for rebleeding prediction. RESULTS: The NVUGIB patients with rebleeding exhibited higher scores, white blood cell counts, d-dimer, CRP, proportion of surgery intervention, and longer hospital stay, but lower hematocrit, hemoglobin, calcium, prealbumin, and fibrinogen than those without rebleeding. The multivariate regression analysis demonstrated that prealbumin and d-dimer were independent predictors for rebleeding. Values of prealbumin and d-dimer were correlated with hospital stay, ulcer degrees, and surgery demand. The ROC curve analyses showed that prealbumin and d-dimer exhibited superior prediction value over the scoring systems. CONCLUSIONS: Prealbumin and d-dimer are promising predictors for severity and prognosis in NVUGIB practice.

Predictive performance of blood urea nitrogen to serum albumin ratio in elderly patients with gastrointestinal bleeding.

INTRODUCTION: Acute gastrointestinal (GI) bleeding is one of the most important and the common causes of patients visiting the emergency department. Dehydrated state leads to increased blood urea nitrogen (BUN) and decreased albumin level. Many scoring systems had been developed to predict outcomes for patients with GI bleeding. Among the many scoring systems, the AIMS65 score was a simple and accurate risk assessment scoring tool. Therefore, in this study, we evaluated the prognostic performance of the blood urea nitrogen to serum albumin ratio (B/A ratio) compared to the AIMS65 score tool in elderly patients with GI bleeding. MATERIAL AND METHODS: This was a retrospective cohort study of patients with GI bleeding in our institution from February 2018 through May 2020. Baseline characteristic data were obtained. The data were compared with the prevalence of ICU admission and in-hospital mortality. The B/A ratio and the AIMS65 score as predictors of ICU admission and in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. RESULTS: In the 596 patients included in the study, of whom 188 (31.5%) were admitted to the ICU and 36 (6.0%) died during hospitalization. Multivariate logistic regression analysis revealed that the B/A ratio was significant predictors of ICU admission and in-hospital mortality. In addition, the B/A ratio was significant higher in ICU admission patients and non-survivors. The AUROC value of the B/A ratio was 0.682 and that of the AIMS65 score was 0.699 for predicting ICU admission. For predicting in-hospital mortality, the AUROC value was 0.770 and 0.763, respectively. CONCLUSION: The B/A ratio is as simple and useful tool for predicting outcomes for old aged GI bleeding patients as the AIMS65 score.

Is Blood Urea Concentration an Independent Predictor of Positive Endoscopic Findings in Presumed Upper Gastrointestinal Bleeding?

BACKGROUND: The test characteristics of blood urea concentration in the identification of upper gastrointestinal bleeding (UGIB) or high-risk endoscopic lesions have not been clearly determined. This study aimed to elucidate if urea independently correlates with the presence of positive endoscopic findings in cases of presumed UGIB and understand the diagnostic value of this parameter when assessing a patient with potential UGIB. METHODS: A retrospective cohort study was conducted at Hamilton Health Sciences hospitals examining patients who had upper endoscopy for presumed UGIB. Contingency tables were generated to determine the test characteristics of urea at different thresholds for prediction of UGIB. A crude OR was calculated for odds of bleeding being identified on endoscopy based on varying thresholds of urea, and adjusted ORs were calculated using logistic regression modelling. RESULTS: Variables significantly associated with detecting a source of GI bleeding at endoscopy included increase in urea (OR 1.06, 95% CI 1.01-1.09), male gender (OR 2.02, 95% CI 1.08-3.77), presence of melena (OR 2.37, 95% CI 1.06-5.33), and hematemesis (OR 3.88, 95% CI 1.70-8.83), when adjusted for other covariates. The odds of identifying UGIB at endoscopy in patients with urea ≥10 mmol/L was 3.73 (95% CI 1.90-7.31) times higher than for patients with urea <10 mmol/L. CONCLUSION: Urea level is an independent predictor of positive endoscopic findings in presumed UGIB, and urea ≥10 mmol/L may be a useful threshold to help guide clinicians towards clinically significant bleeding that could warrant early endoscopic evaluation.

Diagnostic Values of Blood Count Values and Ratios in Distinguishing between Peptic Ulcer Bleeding and Esophagogastric Variceal Bleeding.

BACKGROUND: To investigate the diagnostic values of blood count values and ratios in distinguishing between peptic ulcer bleeding (PUB) and esophagogastric variceal bleeding (EGVB). METHODS: Due to acute hematemesis and or melaena, 57 patients diagnosed with PUB (PUB group) and 33 cases with EGVB (EGVB group) were enrolled in this retrospective study. The levels of peripheral blood leukocyte counts (leukocyte), neutrophil counts (neutrophil), lymphocyte counts (lymphocyte), platelet counts (platelet), neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) were recorded and compared between the two groups. Student's t-test of independent samples was adopted for comparing the mean between the two groups. Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Comparison of AUC was performed using the Z-test. RESULTS: The levels of leukocyte, neutrophil, lymphocyte, platelet, and PLR were significantly increased in PUB group compared with EGVB group (all p < 0.05), while there was no significant statistical difference of NLR (p > 0.05); moreover, AUCs in distinguishing PUB from EGVB were 0.859, 0.811, 0.760, 0.952, and 0.687 for leukocyte, neutrophil, lymphocyte, platelet, and PLR, respectively, and significant differences were observed between platelet and any parameter of the rest (all p < 0.05); finally, the cutoff values were 8 x 109/L in distinguishing between PUB and EGVB (specificity 78.95%, sensitivity 87.88%, and Youden index 0.668) for leukocyte, 5.3 x 109/L (specificity 70.18%, sensitivity 81.82%, and Youden index 0.520) for neutrophil, 1.2 x 109/L (specificity 84.21%, sensitivity 60.61%, and Youden index 0.448) for lymphocyte, 131 x 109/L (specificity 92.98%, sensitivity 90.91%, and Youden index 0.839) for platelet, and 88 (specificity 70.18%, sensitivity 63.64%, and Youden index 0.338) for PLR. CONCLUSIONS: Leukocyte, neutrophil, lymphocyte, platelet and PLR are useful and potential biomarkers in distinguishing between PUB and EGVB; moreover, platelet can demonstrate more accurate and reliable diagnostic value.

Blood platelet function abnormalities in cirrhotic patients with esophageal varices in relation to the variceal bleeding history.

Objective: The study aimed at assessing the effect of thrombocytopenia and platelet function abnormalities on the occurrence of variceal bleeding in patients with cirrhosis. Methods: The results of impedance aggregometry, von Willebrand factor antigen level and thromboelastometry (TEM) with and without the addition of a platelet inhibitor (FIBTEM®, EXTEM® test, respectively) were compared in two patient groups: Group 1 (n = 32) - patients with moderate or large esophageal or gastric varices, who had never had symptoms of acute gastrointestinal bleeding and Group 2 (n = 26) - patients with history of variceal bleeding. Results: Standard clotting test indicated more hypocoagulable profile in Group 2 compared to Group 1. However, no differences in any TEM component were observed between groups in EXTEM® test. The contribution of platelets to clot strength was significantly higher in Group 2 than in Group 1 [PLT% = 74.2 (67.5-80.4) versus 68.8 (63.7-76.5) %; p = .039]. The aggregation index was also higher in Group 2 compared to Group 1, although not statistically significant [% of healthy = 96.9 (73.2-140.1) versus 67.6 (52.5-118.8) %, p = .195]. No differences in vWF antigen levels were observed between groups. Conclusions: The results of thromboelastometry and aggregometry indicate increased contribution of platelets in clot formation in patients with a history of variceal bleeding compared to cirrhotic patients who never bled. Comparable effectiveness of hemostasis in both groups is most likely associated with the compensatory role of platelets. Increased platelet activity in this group of patients is probably due to a mechanism independent of the von Willebrand factor antigen level.

A Case of Acquired Amegakaryocytic Thrombocytopenia with Anti-c-mpl Autoantibody: Comparison with Idiopathic Thrombocytopenic Purpura.

Acquired amegakaryocytic thrombocytopenia (AAMT) is a rare disease that causes severe bleeding. The pathogenesis and treatment of AAMT have not yet been defined. We report the case of a 60-year-old woman diagnosed with AAMT, who presented with severe thrombocytopenia, gastroin-testinal bleeding, and significantly reduced bone marrow megakaryocytes. The patient was treated with methylprednisolone, cyclosporin, and intravenous immunoglobulin. After 2 weeks of treatment, her platelet count started to increase, and her bone marrow megakaryocyte count had normalized 3 months after diagnosis. At the time of diagnosis, the patient was seropositive for anti-c-mpl antibody but was seen to be seronegative once the platelet count recovered. In contrast, anti-c-mpl antibodies were not detected in the serum of 3 patients with idiopathic thrombocytopenic purpura. This case study suggests that anti-c-mpl antibody plays an important role in the development of AAMT, and that intensive immunosuppressive treatment is required for autoantibody clearance and recovery of megakaryocyte count.

Recurrent Severe Iron Deficiency Anemia and Thrombocytopenia in an Adolescent Male.

An adolescent male presented with recurrent episodes over several years of severe iron deficiency anemia and associated severe thrombocytopenia. The anemia was secondary to chronic blood loss due to ulceration at the site of an ileocolonic anastomosis performed during infancy. We were able to demonstrate complete resolution of thrombocytopenia with the administration of iron, and without using steroids, intravenous immunoglobulin, or platelet transfusions. This is the first reported case of an individual with multiple episodes over several years of thrombocytopenia secondary to recurrent severe iron deficiency anemia, illustrating a predisposition to this complication in a unique patient.

Decreased Serum Monocyte Chemoattractant Protein-1 (MCP-1) Expression in Patients with Upper Gastrointestinal Bleeding.

BACKGROUND The aim of this study was to investigate the expression of monocyte chemoattractant protein-1 (MCP-1) and its correlation with the blood lipid level in upper gastrointestinal bleeding (UGIB). MATERIAL AND METHODS A total of 118 patients with UGIB were enrolled in this study. The relevant indicators for blood lipid levels were detected using a biochemical analyzer. MCP-1 levels in the serum of patients was determined through enzyme-linked immunosorbent assay (ELISA). Statistical Product and Service Solutions (SPSS) 17.0 software was used for the statistical analysis. Two-sample t-test was used for the intergroup comparison. The significant indicators were included in a multivariate logistic regression model to analyze the prognostic factors of UGIB. Pearson analysis was applied to the correlation analysis. P<0.05 suggested that the difference was statistically significant. RESULTS MCP-1 expression levels in patients with UGIB were significantly lower than that in the control group and were even further reduced in patients with massive hemorrhage. The levels of total cholesterol (TC), triglyceride (TG), and low-density lipoprotein (LDL) in the serum of patients with UGIB were decreased compared with those in the control group and these indicators of the blood lipid level were decreased much more in patients with massive hemorrhage. The MCP-1 expression was positively correlated with the levels of TC, TG, and LDL in serum. MCP-1 and TC were the prognostic influencing factors of UGIB. CONCLUSIONS Serum MCP-1 expression was significantly decreased in patients with UGIB and correlated with blood lipid level, suggesting it might be a prognostic factor for UGB.

The diagnostic and prognostic value of platelet indices in gastrointestinal bleeding.

BACKGROUND: We aimed to investigate the association between platelet indices [platelet, plateletcrit (PCT), mean platelet volume (MPV) and platelet distribution width (PDW)] and gastrointestinal bleeding (GIB), as well as determine its severity and prognosis. METHOD: 500 patients with GIB who were admitted to hospital between March 2014 and February 2017 and diagnosed with "Gastrointestinal System Bleeding", as well as114 healthy individuals were retrospectively included in the study. Patients' platelet indices were recorded after one week and one month from their files. RESULTS: Platelet, PCT, MPV and PDW levels were determined to be higher in the patients with bleeding, when compared to the control group (p < 0.001). Within the first week, a significant reduction was determined in patients' platelet, PCT, MPV and PDW values compared to the admission values (p < 0.001). In initial-month controls, a significant reduction was determined in the platelet indices compared to the initial-week values (p < 0.001). A significant association between bleeding severity and increased platelet indexes was determined. Increasing age, female gender, the presence of comorbidities, high levels of platelet indexes, low levels of hemoglobin, and albumin values were all found to be associated with a poor prognosis. PCT, MPV, and PDW were determined as being the independent risk factors that predict the odds of GIB, alongside the independent predictors that predict risk of bleeding severity and the prognosis. CONCLUSION: We think that platelet indices may be used in diagnosis of GIB, as well as in predicting bleeding severity and the prognosis.

Experience of the use of octreotide for refractory gastrointestinal bleeding in a patient with Jarvik2000® left ventricular assist device.

Gastrointestinal bleeding (GIB) is among the major complications affecting implantable continuous-flow left ventricular assist device (iLVAD) recipients and is the major cause of re-hospitalization. GIB in iLVAD recipients is sometimes critical, and controlling bleeding using conventional approaches is difficult. A 35-year-old woman developed refractory GIB from multiple gastric polyps and de novo angiodysplasia after Jarvik2000® iLVAD implantation. Discontinuation of anticoagulation and antiplatelet therapies had little effect on GIB; thus, multiple endoscopic hemostatic therapies were performed. However, bleeding recurred several times, and red blood cell (RBC) transfusion in large volumes was required for progressive anemia. Furthermore, the von Willebrand factor (VWF) multimer analysis revealed loss of the high-molecular weight multimer, which may have resulted from the high-speed rotation of the axial-flow LVAD pump. To supplement VWF, cryoprecipitate was administered, but it was effective for only several days. Finally, the patient was treated with octreotide, a somatostatin analog, on post-operative day 58. After starting octreotide, tarry stool gradually decreased, and progression of anemia slowed down within the first 14 days of treatment; thus, the total RBC transfusion volume was reduced without additional hemostatic interventions, including cryoprecipitate administration. The patient developed mediastinitis on post-operative day 68 and died of sepsis on post-operative day 72. There was no adverse effect associated with octreotide use. Although the observation period was short, octreotide appears to be useful for resolving recurrent GIB after iLVAD implantation and reducing blood transfusions.

[Study on correlation between serum 25-hydroxyvitamin D3 level and esophageal variceal bleeding in cirrhotic patients].

Objective: To explore the correlation between serum 25-hydroxyvitamin D3 (25[OH]D(3)) levels and esophageal variceal bleeding (EVB) in cirrhotic patients. Methods: Eighty-three cases with liver cirrhosis hospitalized from November 2016 to January 2017 were collected. The patients were divided into bleeding group (51 cases) and non-bleeding group (32 cases) depending on the presence or absence of bleeding under gastroscopy. Serological tests were performed on both groups, including hemoglobin (Hb), albumin (ALB), alkaline phosphatase (ALP),γ-glutamyltransferase (GGT), interleukin-6 (IL-6), and 25-hydroxyvitamin D3 (25[OH]D(3)). Both groups were analyzed by univariate analysis. The differences between both groups were compared by t-test, after normality test. The other variables were compared by Mann-Whitney U test. The correlation between the relevant variables and EVB were analyzed by Spearman's rank correlation and a multivariate analysis. Cases with primary biliary cirrhosis were relatively low in number (four cases in bleeding group, accounting for 8%, 10 cases in non-bleeding group, accounting for 31%). The effects of ALP and GGT on serum 25(OH)D(3) level were analyzed by stratified analysis. Moreover, ALP and GGT levels were divided into two and three groups: < 140 U/L and >140 U/L and < 30 U/L, > 30 U/L, and ~≤60 U/L. Results: Bleeding group had low levels of hemoglobin (t= -2.827,P= 0.005), alkaline phosphatase (t= -3.097,P= 0.002), gamma-glutamyltransferase (t= -2.292,P= 0.022), and 25(OH)D(3) (t= -3.134,P= 0.002) than non-bleeding group. Both groups (P> 0.05) had similar levels of albumin, interleukin-6, AAR, and FIB-4. Logistic regression analysis showed that 25(OH)D(3), alkaline phosphatase and hemoglobin were independent risk factors for EVB. Spearman's correlation coefficient analysis showed that 25(OH)D(3)was significantly positively and negatively correlated with interleukin-6 (r= 0.306,P= 0.005) and albumin (r= -0.327,P= 0.003). Stratified analysis showed that serum 25(OH)D(3) level was lower in ALP≤140U/L group and the bleeding group, and the difference was statistically significant than non-bleeding group (P= 0.007), while the serum level of 25(OH)D(3)was decreased in both groups for alkaline phosphatase > 140 U/L group, and the difference was not statistically significant (P= 0.051). Furthermore, in the GGT > 60 U/L group, the serum level of 25(OH)D(3)was significantly lower in the bleeding group, and the difference was statistically significant in non-bleeding group (P= 0.003), while the difference between the two groups was not statistically significant (P> 0.05) in GGT≤30 U/ L, > 30 U/L, and ~≤60 U/L group. Conclusion: Serum 25(OH)D(3)level was significantly lower in EVB cirrhotic patients, and it was an independent risk factor for EVB. Serum 25(OH)D(3) low levels was more apparent with ALP normalization or GGT level > 60 U/L.

Quality management of a massive transfusion protocol.

BACKGROUND: Massive transfusion is a response to massive uncontrolled hemorrhage. To be effective, it must be timely and address the patient's needs for blood volume, oxygen transport, and hemostasis. STUDY DESIGN AND METHODS: A review was performed on all activations of the massive transfusion protocol (MTP) in a hospital with large emergency medicine, trauma, and vascular surgery programs. Indications, transfused amounts, and outcomes were determined for each MTP event to determine appropriateness of MTP use. Results are presented as descriptive statistics, categorical associations, and simple linear trend relationships. RESULTS: The MTP was activated 309 times in 2016. Of these episodes, 237 were for trauma, 29 for gastrointestinal bleeding, 16 for ruptured abdominal aortic aneurisms, and 25 for a variety of other causes. Trauma-related MTP activations had a mean injury severity score of 32. Blood use averaged 6.6 units of red blood cells (RBCs), 6.5 units of plasma, and 1.2 units of apheresis platelets. Fourteen activations ended without the administration of any blood products, and 45 (14%) did not meet the critical administration threshold of three components. Only 60 (19%) activations met the historic definition of massive with at least 10 units of RBCs administered. Mortality was 15% for the trauma-related activations. CONCLUSIONS: Massive transfusion protocol activations were frequent and conducted with high fidelity to the 1:1:1 unit ratio standard. Making blood components available quickly was associated with low rates of total component usage and low mortality for trauma patients and was not associated with overuse.

Noninvasive Methods of Predicting Large Esophageal Varices in Children With Intrahepatic Portal Hypertension.

OBJECTIVE: Esophageal variceal bleeding is a severe complication of portal hypertension. The standard diagnostic screening test and therapeutic procedure for esophageal varices (EV) is endoscopy, which is invasive in pediatric patients. This study aimed to evaluate the role of noninvasive parameters as predictors of large varices in children with intrahepatic portal hypertension. METHODS: Participants included in this cross-sectional study underwent a screening endoscopy. Variceal size, red marks, and portal gastropathy were assessed and rated. Patients were classified into two groups: Group 1 (G1) with small or no varices and Group 2 (G2) with large varices. The population consisted of 98 children with no history of gastrointestinal (GI) bleeding, with a mean age of 8.9 ±â€Š4.7 years. The main outcome evaluated was the presence of large varices. RESULTS: The first endoscopy session revealed the presence of large varices in 32 children. The best noninvasive predictors for large varices were platelets (Area under the ROC Curve [AUROC] 0.67; 95% CI 0.57-0.78), the Clinical Prediction Rule (CPR; AUROC 0.65; 95% CI 0.54-0.76), and risk score (AUROC 0.66; 95% CI 0.56-0.76). The logistic regression model showed that children with a CPR value under 114 were 8.59 times more likely to have large varices. Risk scores higher than -1.2 also increased the likelihood of large varices (OR 6.09; P = 0.014), as did a platelet count/spleen size z score lower than 25 (OR 3.99; P = 0.043). The combination of these three tests showed a high negative predictive value. CONCLUSIONS: The CPR, the risk score, and the platelet count/spleen size z score could be helpful in identifying cirrhotic children who may be eligible for endoscopy.

Preoperative Right-Sided Cardiac Congestion Is Associated with Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices.

BACKGROUND: Large scale data on preoperative risk stratification for gastrointestinal bleeding (GIB) following continuous-flow left ventricular assist device (CF-LVAD) implantation are scarce. AIMS: To identify independent predictors for GIB following CF-LVAD implantation. METHODS: We conducted a retrospective cohort study of consecutive 243 patients who underwent CF-LVAD implantation (HeartMateII) from January 2009 to March 2015 at the University of Chicago Medical Center. GIB was defined as the presence of overt bleeding or occult GIB with ≥ 2 g/dl drop in hemoglobin (Hgb) from recorded baseline values and hemoccult-positive stool. The preoperative and postoperative data were reviewed. RESULTS: Within a median follow-up duration of 408 (IQR 113-954) days, 83 (34%) patients developed GIB after a median of 149 (IQR 27-615) days after implantation of CF-LVAD. There were no significant differences between the groups of GIB and non-GIB with respect to preoperative demographics and comorbidity except for ethnicity. The source of bleeding was identified in 39 (47%) patients and arteriovenous malformation or submucosal streaming vessel was the most frequent cause of bleeding (18/39, 46%). Multivariate-adjusted analysis demonstrated preoperative central venous pressure (CVP) ≥ 18 mmHg (HR 3.56; 95% CI 1.16-10.9; p = 0.026), mean pulmonary artery pressure (mPA) ≥ 36 mmHg (HR 4.14; 95% CI 1.35-12.7; p = 0.013), and the presence of moderate/severe tricuspid valve disease (HR 1.01; 95% CI 1.01-3.86; p = 0.046) were associated with the risk of GIB. CONCLUSIONS: In this study, preoperative right-sided cardiac congestion (i.e., increased CVP, mPA and the presence of moderate/severe tricuspid valve disease) was associated with GIB in patients with CF-LVAD.

Short-Term Effect of High-Dose Pantoprazol on Serum and Urinary Magnesium Levels.

BACKGROUND: Proton pump inhibitor (PPI) induced hypomagnesemia is a completely unexplained issue and cases are still being reported. Long-term use is the main factor, but there are a few articles stating that it may also emerge with short-term use. We aimed to evaluate the changes of serum and urine magnesium levels during shortterm high dose pantoprazol treatment. METHODS: The serum and 24-hour urine magnesium levels of 58 patients were evaluated during the course of 2 days. Of 58 patients, 25 were allowed oral intake on the 3rd day of hospitalization and thus, 24-hour urine for 3 days was collected from 33 patients. RESULTS: There were no significant differences in the mean levels of serum magnesium and the median levels of urine magnesium. When the magnesium levels were evaluated by age over and under 60 years, the baseline serum magnesium level was significantly higher than the 1st level in patients aged ≥ 60 years (p = 0.029). The 3rd day serum magnesium level was significantly higher than the baseline and 1st day levels in those aged < 60 years (p = 0.049). CONCLUSIONS: We showed that plasma levels and urinary excretion of magnesium did not change significantly during high-dose pantoprazol treatment. It can be hypothesized that magnesium levels are not affected by PPIs in short-term usage. Age and other contributing factors may have more impact on PPI induced hypomagnesemia. Patients aged over 60 years might be handled carefully under proton pump inhibitors treatment.

Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients.

INTRODUCTION AND AIM: EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia. METHODS: We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL. RESULTS: The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR>1.5, platelet count <50x109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) versus 230 mg/dL (104 - 638), P=0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding. CONCLUSION: low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients' risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.

Neutrophil-to-lymphocyte ratio to predict gastrointestinal bleeding in Henoch: Schönlein purpura.

BACKGROUND: Henoch-Schönlein purpura (HSP) is a common form of vasculitis in children. It typically involves small vessels of the skin, the gastrointestinal (GI) tract, joints, and kidneys. GI involvement is the most severe short-term complication and GI bleeding is a major complication of HSP, but there is no established predictive marker of GI bleeding. Blood neutrophil-to-lymphocyte ratio (NLR) has been proposed as a potentially useful marker of clinical outcome in diseases with an inflammatory component. The aim of this study was to clarify the association of NLR with HSP and investigate the usefulness of NLR as a marker to predict GI bleeding in children with HSP. METHODS: All patients with newly diagnosed HSP were reviewed retrospectively. White blood cell count, hemoglobin, platelet counts, mean platelet volume, neutrophil and lymphocyte count were evaluated. NLR and platelet-to-lymphocyte ratio (PLR) were calculated using complete blood count data. RESULTS: This study involved 141 HSP patients. GI involvement was found in 65 patients (46.1%), and, of these, 15 (10.6%) had GI bleeding. At the time of diagnosis, NLR was significantly higher (P = 0.001) and PLR significantly lower (P = 0.032) in patients with GI bleeding than in those without GI bleeding. On logistic regression analysis, NLR was the only independent predictor of GI bleeding (P = 0.004). The optimal cut-off of NLR for predicting GI bleeding was 2.86 (sensitivity, 73%; specificity, 68%). CONCLUSIONS: NLR, a simple and easily obtainable parameter, is a potential predictive marker of GI bleeding in children with HSP.