Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence

Introduction: The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines.

Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localization of bleeding? 3) Can nasogastric aspiration identify high risk patients that might benefit from earlier endoscopy? 4) Is there evidence for benefit in terms of outcomes from using nasogastric aspiration? 5) Is nasogastric intubation safe in patients with possible esophageal varices? Our review was conducted according to PRISMA guidelines.

Expert commentary: Based on the available literature, nasogastric lavage or aspiration cannot be routinely recommended unless a large properly designed randomized trial (which is currently lacking) proves otherwise. It is a painful and time-consuming procedure with no demonstrated benefit for the patient in terms of outcomes. Other clinical and laboratory parameters, and risk scores, are less invasive and are effective for guiding the stratification and management of patients, while pre-endoscopic erythromycin infusion is a good if not better alternative for improving visualization of the stomach.     

Microalbuminuria and cardiovascular risk

The term 'microalbuminuria' has been introduced to describe a measurable increase in urine albumin excretion, which is still within normal total urine protein excretion levels. Many data suggest that microalbuminuria is of value as an index of vascular damage, especially in hypertension and diabetes, and there is increasing information on its associations with traditional cardiovascular risk factors and its prognostic value. The association between microalbuminuria and peripheral markers of endothelial damage or dysfunction, such as von Willebrand factor, suggests the possibility that microalbuminuria may be a simple, cheap and easy index of endothelial abnormalities in cardiovascular disease. Nevertheless, further information on the value of microalbuminuria in other atherosclerotic vascular complications, such as ischaemic heart disease, stroke and peripheral artery disease is still needed.      

Hoarseness as imminent symptom of aortic aneurysm rupture (Ortner's syndrome).

Ortner's syndrome (cardiovocal syndrome) is the clinical entity of hoarseness due to left recurrent laryngeal nerve palsy caused by cardiovascular disease. We present a case of an 86-year-old woman with hoarseness as a prominent symptom due to a large painless aneurysm of the thoracic aorta, which soon ruptured. Cardiovocal syndrome can be a rare but an important and probably the only major clinical finding of a painless aortic rupture.     

Angiogenesis in myocardial infarction. An acute or chronic process?

BACKGROUND: In the acute phase of myocardial infarction (acute MI) marked endothelial damage occurs within the first 24h following thrombolysis with streptokinase. We investigated whether this is associated with a change in levels of vascular endothelial growth factor (VEGF, possibly marking angiogenesis) in the first 24h post thrombolysis compared to chronic MI patients (defined as MI>3 months previously). METHODS: We recruited 15 patients (nine male, mean age 59+/-SD 10 years) with first-presentation acute MI, who were given 1.5 million U streptokinase over 1h and aspirin 300mg orally as standard treatment. Plasma samples were taken prior to the start of thrombolysis, followed every 15 min for 1h, at 3h and finally at 24h post-thrombolysis. Baseline levels of measured indices in the acute MI patients were compared to two control groups: (i) 26 chronic MI patients (18 male, mean age 59.9+/-7.0 years); and (ii) 26 apparently healthy controls (17 male, mean age 59.6+/-14.1 years). Plasma VEGF and the soluble form of its receptor Flt-1 (sFlt-1) were measured by ELISA. RESULTS: Plasma levels of VEGF were significantly higher in patients with a history of chronic MI compared to patients with acute MI (P=0.007) and healthy controls (P=0.002) with similar levels between acute MI patients and healthy controls (P=0.755). Levels of sFlt-1 in the acute (P=0.013) and chronic (P<0.001) MI groups were lower compared to healthy controls. In the first 24h post-thrombolysis in the acute MI group, levels of sFlt-1 changed significantly (P=0.039), but there was no change in levels of VEGF (P=0.207). CONCLUSION: In the first 24h of acute MI, significant changes in levels of VEGF receptor sFlt-1, but not VEGF, are seen. Plasma VEGF and sFlt-1 levels are markedly changed in chronic MI patients, suggesting that the activation of angiogenesis in MI patients may be a delayed response.     

Stroke-complicated endocarditis with positive lupus anticoagulant--a case report

Twenty to 40% of patients with infective endocarditis (IE) suffer from neurologic complications. Also many and various markers of immunologic activation have been reported in patients with IE and no history of autoimmune or other rheumatologic diseases. The authors present a case of a patient suffering from IE complicated with major cerebrovascular event with concomitant appearance of lupus anticoagulant (LAC). After successful antibiotic treatment there was major clinical improvement with disappearance of LAC. LAC could be added to the list of immunologic markers appearing in the course of infective endocarditis.     

THE ‘VASOVAGAL EFFECT’ OF NITRATES: AN UNDER-RECOGNISED COMPLICATION OF NITRATE USE

SUMMARY Nitrates are useful drugs in cardiovascular medicine. They have a presumed vasovagal effect, which is a rare but often under-recognised complication that is partly caused by central inhibition of the sympathetic nervous system. However, no consistent variable associated with the presumed vasovagal effects following nitrate administration can be identified, and there are only limited reports of the phenomenon in the literature. In fact, the true prevalence of such a complication is unknown, because no data from observational studies exist, although it would seem likely to be a rare event. A greater awareness and recognition of this unusual effect of nitrate use is necessary in view of the increasing use of nitrates. Fortunately, recovery is generally the rule with supportive management.     

A pilot study of streptokinase-induced endothelial injury and platelet activation following acute myocardial infarction

OBJECTIVE: To relate the changes in serum vitamin E, an essential antioxidant, to changes in fibrinogen, as well as indices of endothelial damage [as indicated by plasma markers, soluble thrombomodulin (sTM) and von Willebrand factor (vWf), and an index of platelet activation (soluble P selectin (sPsel)], in myocardial infarction treated with thrombolytic therapy. DESIGN AND SETTING: Prospective longitudinal pilot study in a teaching hospital Coronary Care Unit. SUBJECTS AND INTERVENTION: Seventeen patients (12 men: mean age (62 years +/- SD 11 years) admitted with acute myocardial infarction (AMI), who were given thrombolytic therapy, and 59 healthy controls. RESULTS: Baseline levels of fibrinogen (Mann-Whitney test, P = 0.0055) and vWf (P < 0.001) were significantly higher than controls, but sPsel, sTM or vitamin E levels were not significantly different. Following thrombolysis, as expected, median concentrations of plasma fibrinogen fell profoundly (Friedman ANOVA P < 0.001) so that after 45 min, levels were undetectable in 13 patients. At 24-h median fibrinogen concentration had recovered to approximately 30% of baseline (P < 0.01) and was still undetectable in three patients. Levels of vWf and sPsel increased steadily, reaching significance after three hours (both P < 0.05). However, levels of sTM rose immediately after thrombolysis, peaking between 1 and 3 h, and remained elevated at 24 h. These increases corresponded to a simultaneous early fall in serum vitamin E concentrations. CONCLUSION: The present pilot study demonstrates significant endothelial damage and platelet activation in association with increased oxidative stress following streptokinase therapy for AMI.     

The prevalence of pre-eclampsia and obstetric outcome in pregnancies of normotensive and hypertensive women attending a hospital specialist clinic

To study the prevalence of pre-eclampsia (PE) and other obstetric outcomes (growth restriction and fetal mortality) in pregnancies of normotensive and hypertensive women attending an antenatal hypertension clinic, we studied a cohort of 372 pregnancies from 267 women. The prevalence of PE in the groups of pregnancies of normotensive and chronic hypertensive women was 11.9% (19/159 cases) and 16.0% (34/213 cases) respectively (chi 2 = 1.2, p = 0.27). There were no significant differences in respect of ethnicity, being primi- or multigravida and smoking status or age. Treatment with antihypertensive drugs during pregnancy did not decrease the prevalence of PE. In pregnancies with hypertensive complications (with or without PE) there was a trend towards higher rates of pre-term delivery (< 37 weeks), caesarean section, small for gestational age babies, stillbirth and lower baby birth weight and ponderal index values. Pregnancies in women with uncomplicated hypertension had an increased risk for emergency caesarean section, pre-term delivery (< 37 weeks), birth weight < 2500 g and stillbirth (relative risks [with confidence intervals] 2.5 [1.9-3.2], 2.3 [1.8-2.9], 3.1 [2.5-3.7] and 5.5 [2.6-11.9] respectively) compared with the general hospital obstetric population. After classification according to the type of hypertensive syndrome, a progressively higher risk for fetal growth restriction and adverse perinatal outcome was shown in the hypertensive and pre-eclamptic groups. In chronic hypertension, this was irrespective of superimposed pre-eclampsia or antihypertensive therapy. The high prevalence of PE in chronic hypertensive women (16.0%) was not statistically significant to that of normotensive women (11.9%), reflecting the referral selection of 'high risk' normotensive women to our clinic.