Peptic ulcer bleeding patients with Rockall scores ≥6 are at risk of long‐term ulcer rebleeding: A 3.5‐year prospective longitudinal study

Background and Aim

Patients with high Rockall scores have increased risk of rebleeding and mortality within 30 days after peptic ulcer bleeding, but long‐term outcomes deserve follow‐up after cessation of proton pump inhibitors. The paper aimed to validate whether patients with high Rockall scores have more recurrent ulcer bleeding in a 3.5‐year longitudinal cohort.

Methods

Between August 2011 and July 2014, 368 patients with peptic ulcer bleeding were prospectively enrolled after endoscopic hemostasis to receive proton pump inhibitors for at least 8 to 16 weeks. These subjects were categorized into either a Rockall scores ≥6 group (n = 257) or a Rockall scores <6 group (n = 111) and followed up until July of 2015 to assess recurrent ulcer bleeding.

Results

The proportion of patients with rebleeding during the 3.5‐year follow‐up was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 vs. 3.63 per 100 person‐year, P = 0.004, log–rank test). Among patients with Rockall scores ≥6, activated partial thromboplastin time prolonged ≥1.5‐fold (P = 0.045), American Society of Anesthesiologists physical status class ≥III (P = 0.02), and gastric ulcer (P = 0.04) were three additional independent factors found to increase rebleeding risk. The cumulative rebleeding rate was higher in patients with Rockall scores ≥6 with more than or equal to any two additional factors than in those with fewer than two additional factors (15.69 vs. 7.63 per 100 person‐year, P = 0.012, log–rank test).

Conclusions

Patients with Rockall scores ≥6 are at risk of long‐term recurrent peptic ulcer bleeding. The risk can be independently increased by the presence of activated partial thromboplastin time prolonged ≥1.5‐fold, American Society of Anesthesiologists class ≥III, and gastric ulcer in patients with Rockall scores ≥6.     

Weak up-regulation of serum response factor in gastric ulcers in patients with co-morbidities is associated with increased risk of recurrent bleeding

Background  

Serum response factor (SRF) is crucial for gastric ulcer healing process. The study determined if gastric ulcer tissues up-regulate SRF and if such up-regulation correlated with co-morbidities and the risk of recurrent bleeding.     

Endoscopic papillary large balloon dilation for the treatment of recurrent bile duct stones in patients with prior sphincterotomy

Background  

Endoscopic sphincterotomy (EST) is a standard procedure for the removal of bile duct stones. However, additional EST may increase the risk of bleeding and perforation in patients with prior EST. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative method for removing recurrent common bile duct stones with lower risk of bleeding and perforation. The aim of this study was to evaluate the therapeutic outcomes and complications of EPLBD in patients with recurrent common duct stones who underwent EST previously.     

Dieulafoy's lesion of duodenum: a case report

Background  

Dieulafoy's lesion is an uncommon but important cause of recurrent upper gastrointestinal bleeding. Extragastric location of Dieulafoy's lesion is rare. We report two cases of Dieulafoy's lesion of the duodenum and discuss the management of this extremely uncommon entity.     

Somatostatin Analogues in the Treatment of Recurrent Bleeding from Gastrointestinal Vascular Malformations: An Overview and Systematic Review of Prospective Observational Studies

Background  

Vascular malformation of the gastrointestinal tract is an uncommon cause for gastrointestinal bleeding. Traditionally, gastroenterologists prefer to use endoscopic modalities like argon plasma coagulation and electrocoagulation to treat accessible lesions. The role of somatostatin analogues (octreotide) in preventing recurrent bleeding in these patients is unclear. The use of pharmacological treatments would be useful especially in refractory bleeding, inaccessible lesions and in patients who are at high risk for invasive interventions.     

Impact of a bleeding care pathway in the management of acute upper gastrointestinal bleeding

Objectives  

Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies.     

Risk of recurrence and long-term outcomes after colonic diverticular bleeding

Purpose

Diverticular disease is one of the most common causes of acute lower gastrointestinal bleeding. We aimed to evaluate the natural history, follow-up, and risk factors associated with re-bleeding (recurrence) in patients with colonic diverticular bleeding.

Methods

We reviewed patients with proven colonic diverticular hemorrhage from September 1993 to June 2012 at our institution. Recurrence was the main outcome measure.

Results

We identified 78 out of 95 patients with proven diverticular bleed who were treated non-operatively and were followed up for a median of 57.1 months. Thirty-seven (47 %) of these patients with a median age of 67 years developed recurrent diverticular bleed after a median time of 8.1 months. The bleeding originated from the left colon in 78 (83 %) out of 95 patients in the first bleeding episode and 31(84 %) out of 37 patients during the recurrent bleeding episode. Thirty-six patients (97 %) with recurrent diverticular bleed required surgical intervention. Old age at the time of initial bleeding was associated with recurrence (p?=?0.001). Patients with diverticulitis (p?<?0.0001), peripheral vascular (p?=?0.01), and chronic renal diseases (p?=?0.047) were found to have an increased risk for recurrent colonic diverticular bleed. We only had one perioperative mortality due to postoperative sepsis. All other mortalities were not directly associated with surgery.

Conclusion

Patients with a history of colonic diverticular bleed are prone to recur shortly thereafter. Certain risk factors including increased age, documented diverticulitis, history of peripheral vascular disease, and chronic renal failure may predispose to recurrence.     

Vitamin K Antagonists After 6 Months of Low-Molecular-Weight Heparin in Cancer Patients with Venous Thromboembolism

Background

Low-molecular-weight heparin (LMWH) is the treatment of choice in cancer patients with venous thromboembolism. However, data on continuing LMWH treatment beyond 6 months remain scanty.

New predictive model for acute gastrointestinal bleeding in patients taking oral anticoagulants: A cohort study

Background and Aim

The study developed a predictive model of long‐term gastrointestinal (GI) bleeding risk in patients receiving oral anticoagulants and compared it with the HAS‐BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratios, Elderly, Drugs/alcohol concomitantly) score.

Methods

The study periodically followed a cohort of 508 patients taking oral anticoagulants (66 direct oral anticoagulants users and 442 warfarin users). Absence of GI bleeding at an initial examination and any subsequent GI bleeding were confirmed endoscopically. The bleeding model was developed by multivariate survival analysis and evaluated by Harrell's c‐index.

Results

During a median follow‐up of 31.4 months, 42 GI bleeds (8.3%) occurred: 42.8% in the upper GI tract, 50.0% in the lower GI tract, and 7.1% in the middle GI tract. The cumulative 5 and 10‐year probability of GI bleeding was 12.6% and 18.5%, respectively. Patients who bled had a significantly higher cumulative incidence of all‐cause mortality (hazard ratio 2.9, P < 0.001). Multivariate analysis revealed that absence of proton pump inhibitor therapy, chronic kidney disease, chronic obstructive pulmonary disease, history of peptic ulcer disease, and liver cirrhosis predicted GI bleeding. The c‐statistic for the new predictive model using these five factors was 0.65 (P < 0.001), higher than the HAS‐BLED score of 0.57 (P = 0.145).

Conclusions

Gastrointestinal bleeding increased the risk of subsequent mortality during follow‐up of anticoagulated patients, highlighting the importance of prevention. The study developed a new scoring model for acute GI bleeding risk based on five factors (no‐proton pump inhibitor use, chronic kidney disease, chronic obstructive pulmonary disease, history of peptic ulcer disease, and liver cirrhosis), which was superior to the HAS‐BLED score.     

Variceal Band Ligation in the Prevention of Variceal Bleeding: A Multicenter Trial

Background/Aim:

Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients.

Patients and Methods:

We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding.

Results:

The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers.

Conclusions:

A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.     

Identification of HTA as a novel-specific marker for human hepatocellular carcinoma

Background  

Hepatocellular carcinoma (HCC) is the most common malignancy in the world, especially in China. Early diagnosis of new and recurrent hepatocellular carcinoma, followed by timely treatment, will help decrease mortality. Currently biomarkers are not satisfactory. Better diagnostic methods are highly demanded.     

Arterial Ischemic Events Are a Major Complication in Cancer Patients with Venous Thromboembolism

Background

Venous thromboembolism is common in patients with malignancies, affecting up to 10% of this patient population. The association between arterial ischemic events and venous thromboembolism also has been established. However, the influence of arterial ischemic events on outcomes in cancer patients with venous thromboembolism has not been fully determined.

Adherence and Adequacy of Therapy for Esophageal Varices Prophylaxis

Aims  

Esophageal varices (EVs) are prevalent among cirrhotics and their bleeding leads to substantial morbidity and mortality. Management guidelines available during this study recommended beta-blocker therapy for primary prophylaxis and beta-blocker or band ligation (EVL) for secondary prophylaxis. We evaluated prophylaxis practice patterns.     

Testicular vein thrombosis: Incidence of recurrent venous thromboembolism and survival

Purpose

Testicular vein thrombosis (TVT) etiology, recurrence, and survival were compared with lower extremity deep vein thrombosis (DVT) in order to determine whether treatment guidelines for DVT could be applied to TVT.

Patients and Methods

An inception cohort of patients with confirmed TVT (January 1995‐October 2015) was compared to a control group of patients with lower extremity DVT matched by age, gender, and diagnosis date.

Results

Thirty‐nine men with TVT were identified; 15 (38%) with isolated TVT. Left testicular vein was affected in 77% patients; there were no cases of bilateral TVT. Cancer was over twofold more common in TVT patients (59% vs 28%, P = .01). Most cancers (78%) involved organs in proximity to the testicular vein. Although TVT patients were less frequently treated with anticoagulants (49% vs 97%, P = .0001), recurrence rates were similar to DVT group (TVT 4.2 vs DVT 1.1 per 100 patient‐years, P = .11). Despite higher cancer prevalence, survival rates were similar between groups (31% vs 28%; P = .34). Major bleeding events were rare (one patient per group).

Conclusions

Identifying TVT should prompt a search for a regional malignancy. Despite the high cancer prevalence and low utilization of anticoagulants, recurrent venous thrombosis and mortality rates are similar to DVT patients.     

Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis

Background

Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited.

Objectives

To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients.

Methods

Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan−Meier survival analysis, with logrank testing for statistical significance.

Results

Seventy-five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes.

Conclusions

Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.     

Acquired haemophilia in cancer: A systematic and critical literature review

Aim

There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer.

Methods

Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding.

Results

Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37‐86 years) and females (range 43‐89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases.

Conclusion

CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.     

Pre-operative synovial hyperaemia in haemophilia patients undergoing total knee replacement and the effects of genicular artery embolization: A retrospective cohort study

Aim

Haemophilia is characterized by recurrent joint bleeding caused by a lack of clotting factor VIII or IX. Due to repeated joint bleeding, end-stage arthropathy occurs in relatively young patients. A total knee replacement (TKR) can be a solution. However, TKR may be complicated by perioperative and postoperative bleeds despite clotting factor therapy. The aim of this study was to evaluate the prevalence of pre-operative synovial hyperaemia and the effects of Genicular Artery Embolization on synovial hyperaemia and 3-month postoperative joint bleeding.

Methods

In this retrospective cohort study, all patients with haemophilia who underwent periarticular catheter angiography between 2009 and 2020 were evaluated after written informed consent. Synovial hyperaemia on angiography was scored by an interventional radiologist.

Results

Thirty-three angiography procedures in 24 patients were evaluated. Median age was 54.4 years (IQR 48.4–65.9). Preoperative synovial hyperaemia was observed in 21/33 joints (64%). Moderate and severe synovial hyperaemia was observed in 10/33 joints (30%). Synovial hyperaemia decreased in 13/15 (87%) joints after embolization. Three-month postoperative joint bleeding occurred in 5/32 joints: in 2/18 joints (11%) without synovial hyperaemia and in 3/14 joints (21%) with mild synovial hypertrophy. Non-embolized and embolized joints did not differ regarding 3-month postoperative bleeding (P = .425). No complications were observed after embolization.

Conclusion

One-third of patients with haemophilia requiring a TKR had moderate or severe synovial hyperaemia which can be reduced safely by Genicular Artery Embolization prior to TKR. Three-month postoperative bleeding appears to occur independently of the presence of residual mild synovial hyperaemia.     

Comparative efficacy and safety of low‐intensity warfarin therapy in preventing unprovoked recurrent venous thromboembolism: A systematic review and meta‐analysis

Background

Although there exists potential risk of bleeding, extended ‘lifelong’ conventional‐intensity [international normalized ratio (INR): 2.0‐3.0] warfarin anticoagulation is recommended for unprovoked venous thromboembolism (VTE) patients because of risk of recurrent VTE. Whether long‐term low‐intensity (INR: 1.5‐2.0) warfarin therapy reduced the risk of major bleeding without substantially lowered antithrombotic efficacy is not well understood. The aim of this study was to perform a systematic review and meta‐analysis to evaluate the risk‐benefits of low‐intensity warfarin therapy.

Methods

We conducted a comprehensive search of electronic databases and included randomized control trials (RCTs) that reported efficacy (recurrent VTE) and safety (bleeding episodes) of low‐intensity warfarin therapy compared with conventional‐intensity warfarin or placebo from inception through Jun 2016.

Results

Four RCTs reporting high GRADE quality evidence were included. Although the relative risk of recurrent VTE with low‐intensity therapy was significantly increased [2.96 (95% CI: 1.40 to 6.24), P < .004] compared to conventional‐intensity warfarin, there was significant decrease of relative risk when compared with placebo [0.37 (95% CI: 0.24 to 0.56), P < .00001]. As per included publications, no significant major bleeding episodes were observed in low‐intensity warfarin group.

Conclusions

Although less effective than conventional‐intensity warfarin therapy this meta‐analysis indicates that long‐term low‐intensity warfarin therapy is highly effective for preventing recurrent VTE than placebo, along with reduced risks of major bleeding and minimizing potential complications.     

The Bleeding Risk Score as a Mortality Predictor in Patients with Acute Coronary Syndrome

Background

It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied.

Objective

The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center.

Methods

Out of 1,655 patients with ACS (547 with ST-elevation ACS and 1,118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1,416. Mortality information and hemorrhagic complications were also obtained.

Results

Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001).

Conclusions

Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.     

Changes in the Clinical Outcomes of Variceal Bleeding in Cirrhotic Patients: A 10-Year Experience in Gangwon Province, South Korea

Background/Aims

Variceal rupture is one of the main causes of mortality in cirrhotic patients. However, there are limited data on the long-term outcomes of variceal bleeding.

Methods

We investigated the incidence and mortality of variceal bleeding at three endoscopic centers in Gangwon province during 3 periods (August 1996 to July 1997, August 2001 to July 2002, and August 2006 to July 2007).

Results

A total of 1,704 upper gastrointestinal (GI) bleedings occurred during the study periods. Peptic ulcers were found in 825 patients (48.5%), and variceal ruptures were found in 607 patients (35.6%). The variceal bleeding rate did not decrease in each period (26.0% vs 43.7% vs 33.9%, respectively). In the variceal bleeding group, the 6-week mortality rate steadily and significantly decreased (15.5% vs 10.8% vs 6.4%, respectively, p=0.027). In addition, the mortality rate was significantly higher in the variceal bleeding group than in the non-variceal bleeding group (10.4% vs 2.0%, p<0.001; odds ratio, 5.659; 95% confidence interval, 3.445 to 9.295).

Conclusions

Variceal bleeding was still the major cause of upper GI bleedings and did not decrease in prevalence over the 10-year period in Gangwon province, South Korea. However, the mortality rate of variceal bleeding decreased significantly.