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.

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.

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.

Gastrointestinal stromal tumors characteristics in Croatian Northern Adriatic region.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) have fairly recently been identified as a new type of tumor, thanks to advances in immunohistochemistry. Aim of our work was to investigate and describe GISTs in our hospital in a 10-year period. METHODOLOGY: Records of patients treated for GIST were analyzed and data describing demographics, comorbidities, primary tumor site, initial symptoms, immunohistochemical characteristics, method of detection and grade of malignancy were shown for each patient. RESULTS: A total of 31 patients were analyzed. There was 54.8% of women and 46.7% of men with GIST. The mean age was 61.9±12.8 years. Predominant symptoms and signs were abdominal pain and anemia, bloody stool or melena, even though a significant portion of patients did not have any, or only mild symptoms. Stomach was the most frequent location of the tumor. CD117 was positive in all but two biopsy specimens. CONCLUSIONS: We observed approximately the same incidence of GISTs as in other published data. However, we reported less asymptomatic cases at the time of diagnosis. Also, we reported more women diagnosed with GIST in our population. Even though many tumors were diagnosed by other methods, immunohistochemistry remains the definitive diagnostic method.

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.

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.

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.

Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice.

OBJECTIVES: Changing patterns in medical practice may contribute to temporal changes in the incidence of upper and lower gastrointestinal (GI) complications. There are limited data on the incidence of lower GI complications in clinical practice and most studies that have been done have serious methodological limitations to inferring the actual burden of this problem. The aims of this study were to analyze time trends of hospitalizations resulting from GI complications originating both from the upper and lower GI tract in the general population, and to determine the risk factors, severity, and clinical impact of these GI events. METHODS: This was a population-based study of patients hospitalized because of GI complications in 10 general hospitals between 1996 and 2005 in Spain. We report the age- and gender-specific rates, estimate the regression coefficients of the upper and lower GI event trends, and evaluate the severity and associated risk factors. GI hospitalization charts were validated by an independent review of large random samples of unspecific and specific codes distributed among all hospitals and study years. RESULTS: Upper GI complications fell from 87/100,000 persons in 1996 to 47/100,000 persons in 2005, whereas lower GI complications increased from 20/100,000 to 33/100,000. Overall, mortality rates decreased, but the case fatality remained constant over time. Lower GI events had a higher mortality rate (8.8 vs. 5.5%), a longer hospitalization (11.6+/-13.9 vs. 7.9+/-8.8 days), and higher resource utilization than did upper GI events. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) without concomitant proton pump inhibitor was more frequently recorded among upper GI complications than among lower GI complications. When comparing upper GI events with lower GI events, we found that male gender (adjusted odds ratio (OR): 1.94; 95% confidence interval (CI): 1.70-2.21), and recorded NSAID use (OR: 1.92; 95% CI: 1.60-2.30) were associated to a greater extent with upper GI events, whereas older age (OR: 0.83; 95% CI: 0.77-0.89), number of comorbidities (OR: 0.91; 95% CI: 0.86-0.96), and having a diagnosis in recent years (OR: 0.92; 95% CI: 0.90-0.94) were all associated to a greater extent with lower GI events than with upper GI events after adjusting for age, sex, hospitalization, and discharge year. CONCLUSIONS: Over the past decade, there has been a progressive change in the overall picture of GI events leading to hospitalization, with a clear decreasing trend in upper GI events and a significant increase in lower GI events, causing the rates of these two GI complications to converge. Overall, mortality has also decreased, but the in-hospital case fatality of upper or lower GI complication events has remained constant. It will be a challenge to improve future care in this area unless we develop new strategies to reduce the number of events originating in the lower GI tract, as well as reducing their associated mortality.

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.

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.

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.

Recurrent intussusception. Risks and features.

OBJECTIVE: To determine the risk factors associated with recurrent intussusception (RI) and to characterize the timing, features, and complications of RI. DESIGN: Retrospective chart review. SETTING: Children's Hospital and Medical Center, Seattle, Wash. PARTICIPANTS: All patients with a diagnosis of intussusception who underwent barium enema as treatment for reduction between October 1, 1979 and December 31, 1990. Children with RI (N = 23, seven with two or more recurrent episodes) were classified as the case group; children with a single intussusception (N = 234), controls. RESULTS: There were no statistically significant differences in age, sex, race, symptoms, duration of symptoms, or results of the physical examination between the case group and controls. Reduction of the initial intussusception by a barium enema occurred in 96% of patients in the case group vs 62% of the controls (odds ratio, 13.50; 95% confidence intervals, 2.10 to 563.4; P = .003). Only one of 33 episodes of RI followed an operative reduction. In comparing the first recurrent episode with the initial episode, there was a significant reduction in the proportion of patients presenting with lethargy (0% vs 30%; Fisher Exact Test, P = .009) or blood in the stool (5% vs 52%; P < .002) and a drop in the median duration of symptoms from 20 to 6 hours. CONCLUSIONS: Recurrent intussusception cannot be predicted by presenting features or symptoms; operative reduction due to a failed reduction by a barium enema reduces the risk of RI; and patients with RI have fewer symptoms with a shorter duration.

[Bleeding of gastric ulcers. Epidemiologic, clinical and functional characteristics]. / Il sanguinamento da ulcera gastrica. Caratteristiche epidemiologiche, cliniche e funzionali.

The frequency of gastrointestinal haemorrhage due to gastric ulcer has been assessed in 254 personally observed patients suffering from this endoscopically verified pathology. 56 patients, namely 22% of the cases, presented haematemesis and/or melena of the ulcerative lesion. This subgroup was compared with 65 patients with endoscopically verified gastric ulcer without previous bleeding episodes from the lesion in their clinical history, in respect of certain epidemiological, clinical and biohumoral features. The purpose of the study was to check the possible existence of clinical and/or physiopathological differences between subjects with bleeding gastric ulcer and the population of non-bleeding ulcer patients. In 80% of patients studied, the gastric ulcerous disease started with digestive haemorrhage and it was not accompanied by dyspeptic-painful symptomatology in 20% of cases. The pain symptomatology does not appear to be influenced by the intake of non-steroid anti-phlogistic drugs. No significant difference emerges between the two groups considered as regards epidemiological features and biohumoral data (PG I, gastrin, B.A.O. and M.A.O.).

[An analysis of a general prospective series of 3270 upper digestive hemorrhages]. / Análisis de una serie general prospectiva de 3,270 hemorragias digestivas altas.

The results of a global (general series of 3,270 episodes of upper gastrointestinal haemorrhage (UGH) admitted to our unit between the 15th of April 1983 and the 15th of April 1988 have been analyzed. All the patients entered a prospective protocol with 29 variables. Diagnostic and therapeutic approaches had previously been defined. The incidence of UGH in this area was 160 bleeding episodes/100,000 inhabitants/year. Mean age was 57 +/- 16.8 years and male/female ratio was 2.66/1. The percentage of patients older than 65 years was 33.85%. A history of non-steroidal anti-inflammatory drugs (NSAID) intake within 48 hours before the bleeding episode was obtained in 27.63%. Continued alcohol ingestion was observed in 25.96% and 34.37% of patients gave a history of a previous episode of bleeding. UGH presented with haematemesis and melena in 56% of cases, and 44% only with melena. On admission the bleeding was haemodynamically severe in 12.96% and a 19.69% of the patients had severe associated diseases. Early endoscopy in cases with UGH due to peptic ulcer revealed active bleeding in 16.35% (2.87% in jet and 13.48% oozing) and recent clot/visible vessel in 31.7%. The major causes of bleeding were peptic ulcer (54.31%), esophageal and gastric varices (10.73%) and acute lesions of the gastric mucosa (ALGM) (6.72%). Etiology of the haemorrhage could not be established in 8% of cases. Bleeding was persistent in 20.75% and limited in 79.25% of patients. Emergency surgery was needed in 14.43% of cases. The global mortality of the series was 7.65%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Epidemiologic and diagnostic observations on hemorrhage of the upper gastroenteric tract]. / Osservazioni epidemiologiche e diagnostiche sulle emorragie del tratto gastroenterico superiore.

Acute upper gastrointestinal (GI) bleeding causes, according to the authors' experience, 1.65% of all annual hospitalizations. Mortality rate among high risk patients is about 20% and cirrhotic patients have a particularly poor outcome (70% of deaths caused by gastrointestinal hemorrhage). Endoscopy has been performed in 329 cases to identify the active site of bleeding (7.22% of 4791 "EGDS" performed from 1984 to 1988). In this retrospective study gastric and duodenal peptic diseases, have been observed more frequently than esophageal varices ruptures (11.8%) and in 25% of patients Gl bleeding was associated with the use of potentially dangerous drugs (NSAID and/or Steroids). A prompt endoscopy is fundamental to recognize the etiology and for a better management of the patient; unfortunately, even if improvements have been obtained in the diagnosis and therapy, the mortality caused by gastrointestinal hemorrhage is not significantly reduced.

Approach to bloody stools in adults.

The mortality from LIB is less than 5%. The bleeding in the majority of patients with LIB resolves spontaneously and usually leaves no lasting sequelae. Early colonoscopy may shorten the length and cost of hospitalization.

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.

Peptic ulcer disease in children: an uncommon disorder with subtle symptomatology.

BACKGROUND/AIMS: Data concerning peptic and infectious ulcers in children are limited. The aim of the study was to investigate the prevalence, presenting symptoms and significance of symptomatology in ulcer diagnosis in the pediatric age group. MATERIALS AND METHODS: Between January 2000 and 2009, upper gastrointestinal endoscopy charts were examined retrospectively. All children in whom a diagnosis of ulcer was established were included in the study. Demographic, clinical, endoscopic, and histopathologic data were obtained from the patients' records. Peptic ulcer disease prevalence, presenting symptoms and symptomatology were evaluated. RESULTS: Ulcer disease was observed in 31 (3.4%) of 902 patients. The mean age was 10.85 ± 4.25 (range: 2-17 years), and the male to female ratio was 2:1. The most common symptom was chronic abdominal pain (68%), hematemesis and melena (55%) and vomiting (39%). Helicobacter pylori was identified in 19 patients (61%) with ulcer. In the Helicobacter pylori-positive group, upper intestinal bleeding and pain were the major symptoms. Symptom frequency was not different between Helicobacter pylori-positive and -negative patients (p>0.05). CONCLUSIONS: Ulcer disease is an uncommon disorder in children with nonspecific clinical symptoms. Unlike the adult population, symptoms fail to diagnose peptic ulcer disease before gastrointestinal bleeding occurs.

Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm.

OBJECTIVE: To derive and validate an algorithm to estimate the absolute risk of having ovarian cancer in women with and without symptoms. DESIGN: Cohort study with data from 375 UK QResearch general practices for development and 189 for validation. PARTICIPANTS: Women aged 30-84 without a diagnosis of ovarian cancer at baseline and without appetite loss, weight loss, abdominal pain, abdominal distension, rectal bleeding, or postmenopausal bleeding recorded in previous 12 months. Main outcome The primary outcome was incident diagnosis of ovarian cancer recorded in the next two years. METHODS: Risk factors examined included age, family history of ovarian cancer, previous cancers other than ovarian, body mass index (BMI), smoking, alcohol, deprivation, loss of appetite, weight loss, abdominal pain, abdominal distension, rectal bleeding, postmenopausal bleeding, urinary frequency, diarrhoea, constipation, tiredness, and anaemia. Cox proportional hazards models were used to develop the risk equation. Measures of calibration and discrimination assessed performance in the validation cohort. RESULTS: In the derivation cohort there were 976 incident cases of ovarian cancer from 2.03 million person years. Independent predictors were age, family history of ovarian cancer (9.8-fold higher risk), anaemia (2.3-fold higher), abdominal pain (sevenfold higher), abdominal distension (23-fold higher), rectal bleeding (twofold higher), postmenopausal bleeding (6.6-fold higher), appetite loss (5.2-fold higher), and weight loss (twofold higher). On validation, the algorithm explained 57.6% of the variation. The receiver operating characteristics curve (ROC) statistic was 0.84, and the D statistic was 2.38. The 10% of women with the highest predicted risks contained 63% of all ovarian cancers diagnosed over the next two years. CONCLUSION: The algorithm has good discrimination and calibration and, after independent validation in an external cohort, could potentially be used to identify those at highest risk of ovarian cancer to facilitate early referral and investigation. Further research is needed to assess how best to implement the algorithm, its cost effectiveness, and whether, on implementation, it has any impact on health outcomes.