Upper GI bleeding requires prompt investigation

Upper GI bleeding is a common medical emergency with an incidence in the UK of 103 cases per 100,000 adults per year and is much more common in the elderly. The most common presenting signs are haematemesis (bright red or 'coffee ground') and melaena. About 30% of patients with bleeding ulcers present with haematemesis, 20% with melaena, and 50% with both. Up to 5% of patients with bleeding ulcers have haematochezia and this indicates heavy bleeding into the upper GI tract. An upper GI bleeding source should be considered when haematochezia presents with signs and symptoms of haemodynamic compromise. Peptic ulcer disease, both gastric and duodenal, accounts for the majority of admissions for upper GI bleeding. Other causes of bleeding include mucosal (Mallory-Weiss) tear of the gastro-oesophageal junction secondary to vomiting, and multiple types of vascular abnormalities. Clinical risk factors for mortality in upper GI bleeding are age, comorbidity, tachycardia and a low systolic blood pressure. Given the high mortality rate associated with upper GI bleeding nearly all patients with symptoms described above should be referred to secondary care for emergency admission and endoscopic assessment. This should also be the default position in borderline cases. Early endoscopy in upper GI bleeding: allows early diagnosis; provides the opportunity for endoscopic haemostasis; enables complete risk stratification of non-variceal bleeding and allows early discharge of patients with low-risk findings.     

急诊上消化道出血186例临床分析

目的:探讨急诊科上消化道出血的病因构成及特点.方法:回顾性分析我科2010年1月至2012年1月诊治的186例上消化道出血患者的临床资料.结果:(1)上消化道出血主要病因为消化性溃疡46.9％、急性胃黏膜病变12.7％、肝硬化9.0％、胃癌7.2％,贲门撕裂症6.0％.(2)急诊内镜诊断明确的阳性率(95.6％)显著高于非急诊内镜(81.3％),P＜0.01.(3)服用非甾体消炎药(NSAIDs)患者急性胃黏膜病变发生率(39.5％)明显高于未服用者(4.1％),P＜ 0.01;服用NSAIDs患者消化性溃疡发生率(52.6％)虽高于未服用者(39.2％),但差异无统计学意义,P＞ 0.05.结论:服用NSAIDs是上消化道出血的重要原因,急性胃黏膜病变发生率较前有所增加,急诊内镜检查有助于上消化道出血的诊断.     

Upper gastrointestinal endoscopy in octogenarians.

A retrospective study of upper gastrointestinal endoscopy (GIE) in 217 octogenarians performed over a two-year period in a district general hospital was carried out. It showed that upper GIE in octogenarians is a safe and easy as in other age groups, and provides more useful information. Patients were referred mainly by the geriatricians for elective endoscopy, reflecting the growing recognition of the value of elective upper GIE in the very elderly. The incidence of peptic ulcer disease as a cause of upper GI bleeding was much less than previously reported. Thirty-nine patients with upper GI haemorrhage had an endoscopy within 24 hours. We believe that this helps to identify patients with a high risk of mortality and those who might benefit from early surgery. Eighty per cent of the patients had one or more associated diseases, but there were no complications from endoscopy. We would like to emphasise that there is no contraindication for upper GIE in very elderly patients.     

Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study

BACKGROUND AND STUDY AIMS: In previous randomized trials, early endoscopy improved the outcome in patients with bleeding peptic ulcer, though most of these studies defined "early" as endoscopy performed within 24 hours after admission. Using the length of hospital stay as the primary criterion for the clinical outcome, we compared the results of endoscopy done immediately after admission (early endoscopy in the emergency room, EEE) with endoscopy postponed to a time within the first 24 hours after hospitalization, but still during normal working hours ("delayed" endoscopy in the endoscopy unit, DEU). PATIENTS AND METHODS: We conducted a retrospective analysis of data from 81 consecutive patients with bleeding peptic ulcer admitted in 1997 and 1998 (age range 16 - 90 years). Of these 81 patients, 38 underwent DEU (the standard therapy at the hospital) and 43 underwent EEE. Patients in the two groups were comparable with regard to admission criteria, were equally distributed with respect to their risk of adverse outcome (assessed using the Baylor bleeding score and the Rockall score), and differed only in the treatment they received. Endoscopic hemostasis was performed whenever possible in all patients with Forrest types I, IIa, and IIb ulcer bleeding. RESULTS: We found similar rates in the two groups for recurrent bleeding (16 % in DEU patients vs. 14 % in EEE patients), persistent bleeding (8 % in DEU patients vs. none in EEE patients), medical complications (21 % in DEU patients vs. 26 % in EEE patients), the need for surgery (8 % in DEU patients vs. 9 % in EEE patients), and the length of hospital stay (5.1 days for DEU patients vs. 5.9 days for EEE patients). None of the differences between the two groups in these parameters were statistically significant. None of the patients died. CONCLUSIONS: Early endoscopy in an emergency room did not improve the clinical outcome in our 81 consecutive patients with bleeding peptic ulcer.     

The management of acute upper gastrointestinal bleeding

Acute upper gastrointestinal (GI) bleeding is one of the most common medical emergencies and most cases require urgent medical assessment. Half of all cases are due to peptic ulcer and this article focuses on non-variceal bleeding. The priority, following emergency hospital admission, is to support the circulation of the shocked patient rather than to identify the source of bleeding. After resuscitation the patient can have an endoscopy procedure. It is important that all nurses are fully aware of the signs, symptoms, and management of acute upper GI bleeding, issues that are all addressed in this article.     

Overlooked lesions at emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS: Excessive blood covering the examination field is a frequent cause of diagnostic failure in emergency endoscopy for acute upper gastrointestinal bleeding. The implications and outcome in these patients have not been well described. PATIENTS AND METHODS: The records for 1459 consecutive patients who presented at our medical center with acute nonvariceal upper gastrointestinal bleeding during a 15-month period were reviewed. All of the patients underwent emergency endoscopy within 24 h of initial presentation. Patients in whom an identifiable bleeding source was not found in spite of an overtly bloody lumen were designated as having a failure of diagnosis, and these cases were analyzed further. RESULTS: Diagnosis failed in 25 patients (1.7 %), 16 of whom underwent repeat endoscopy or surgical intervention. Bleeding vessels were identified in 13 of these patients. Gastric and duodenal ulcers were the most commonly overlooked lesions, with locations in the cardia (n = 3), fundus (n = 2), posterior wall of the antrum (n = 1), duodenal bulb (n = 3), second part of the duodenum (n = 2), and in the stoma of a Billroth II gastrectomy (n = 2). The rates for endoscopic complications, recurrent bleeding, surgery, and mortality were significantly higher in the group with diagnostic failure than in patients with acute upper gastrointestinal bleeding in whom diagnosis did not fail (8 % vs. 0.4 %; 20 % vs. 3.1 %; 16 % vs. 2.9 %; and 20 % vs. 3.6 %, respectively). CONCLUSIONS: In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.     

A new and effective technique of Yag laser photocoagulation for severe upper gastrointestinal bleeding

A new technique of treating acute severe upper gastrointestinal haemorrhage was evaluated. The technique consisted of epinephrine injections in the bleeding lesion combined with YAG laser radiation in short pulses, applied until the bleeding vessel was completely closed. This new treatment modality was tried in 54 consecutive patients with severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a non-bleeding visible vessel in the floor of the ulcer crater at endoscopy. Permanent haemostasis was achieved in 87% of the 54 patients. Emergency surgery was needed in 13%. The mortality rate was only 10%. No complications occurred. It is concluded that this new technique of treating severe upper gastrointestinal bleeding from a spurting artery, or an ulcer with a visible vessel results in a significant improvement of the success rate (permanent haemostasis) and a marked reduction in the mortality rate.     

Peptic ulcer with a visible non-bleeding vascular wall--early elective surgery or endoscopic therapy?

The records of 71 patients with the endoscopic finding of a peptic ulcer with a non-bleeding visible vessel, treated between 1982 and 1987 were retrospectively analysed. 16 patients underwent early surgical treatment (group I), 15 patients were treated conservatively (group II) and 40 patients by endoscopic haemostasis (group III). Recurrent bleeding was observed in 6.25% patients in group I, in 53.3% in group II and in 25% in group III, in which case endoscopy was performed again. The patients with arterial bleeding underwent early elective operation after endoscopic haemostasis. Deaths occurred only in the postoperative period: group I 6.25%, group II 13%, and group III 5%. These findings indicate that primary endoscopic treatment in selected patients leads to results equal to those achieved with early surgery. Conservative therapy cannot, however, be recommended.     

Treatment of peptic ulcer related to rheumatic diseases

Rheumatic diseases often have gastrointestinal(GI) manifestations, and may present as GI bleeding and perforation due to peptic ulcer associated with high mortality. Major causes of peptic ulcer related to rheumatic diseases are drugs such as nonsteroidal anti-inflammatory drug(NSAID) and corticosteroid, and vasculitis. The analgesic effects of NSAID often mask abdominal pain until they cause GI bleeding and perforation. Therefore, it is important to make early diagnosis of peptic ulcer with upper gastrointestinal endoscope. Fundamental treatment of NSAID induced peptic ulcer is to quit it, however it is difficult because of activity of rheumatic diseases. Also, most NSAID induced peptic ulcers heal by administration of proton pump inhibitor or misoprostol. Corticosteroid pulse therapy or administration of immunosuppressant agents is effective for vasculitis induced peptic ulcer, however it is difficult to make diagnosis of it. Development of NSAID with less side effects such as cyclooxygenase-2 selective inhibitors and establishment of diagnosis and treatment of peptic ulcer related to rheumatic diseases are expected.     

奥美拉唑治疗消化性溃疡并上消化道出血78例临床分析

目的:总结奥美拉唑治疗消化性溃疡并上消化道出血的临床疗效和安全性。方法:回顾性分析201 1年1月至2012年12月收治的经胃镜确诊的消化性溃疡并上消化道出血患者78例的临床资料。结果:本组78例中,止血的总有效率为93.6%(73/78),无效率为6.4%(5/78)无1例死亡;未发现严重不良反应。结论:奥美拉唑治疗消化性溃疡并上消化道出血的临床疗效确切,副作用小。     

3042例上消化道出血患者病因分析及护理对策

目的 探讨3042例上消化道出血患者的病因,并提出护理对策.方法 回顾性分析本院1991年3月～2009年3月3042例上消化道出血住院患者的病因,并提出对策.结果 消化性溃疡出血为上消化道出血的主要病因,占46.96％,其中十二指肠溃疡呈下降趋势;急性胃黏膜病变为上消化道出血的第2病因,占28.76％,呈上升趋势;年龄＜60岁组患者十二指肠溃疡是上消化道出血的主要病因(占44.35％),年龄≥60岁组患者急性胃黏膜病变为上消化道出血的主要病因(41.21％).结论 消化性溃疡出血与急性胃黏膜病是上消化道出血的主要病因,其中十二指肠溃疡呈下降趋势,其也是年龄＜ 60岁组患者的主要病因;急性胃黏膜病变呈上升趋势,其也是年龄≥60岁患者的主要病因.在护理工作中,应针对不同年龄患者病因与疾病谱变化情况,开展针对性的健康教育,促进患者行为改变,从而达到防病、治病的目的.     

Prediction of mortality at endoscopy in bleeding peptic ulcer disease

One hundred and forty two patients with bleeding peptic ulcers underwent emergency endoscopy. Seventy six had endoscopic stigmata of haemorrhage and nine subsequently died. There were no deaths amongst sixty six patients without stigmata (p less than 0.02). Patients with stigmata were also significantly more likely to experience further bleeding (p less than 0.001) and to require emergency operations (p less than 0.01). Excess risk attached to those with bleeding at the time of endoscopy and those with visible vessels or clot adherent to the ulcer but not to patients with staining of the ulcer base. Patients without stigmata or with staining alone should be managed conservatively. Clinical trials in bleeding peptic ulcer disease should only include patients in the high risk group.     

Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding

OBJECTIVE: The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalization. DESIGN: Cost-effectiveness investigation. Four clinical scenarios were considered: scenario 1, diagnostic endoscopy with oral PPI therapy; scenario 2, diagnostic and therapeutic endoscopy with high-dose intravenous PPI therapy; scenario 3, diagnostic and therapeutic endoscopy available with oral PPI therapy; and scenario 4, diagnostic and therapeutic endoscopy (no PPI). Effectiveness was evaluated in terms of episodes of bleeding averted and quality-adjusted life years. SETTING: University teaching hospital in the United States. PATIENTS: Hospitalized patients with acute peptic ulcer bleeding. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Therapeutic endoscopy with high-dose intravenous PPI therapy (scenario 2) was the most cost-effective approach in terms of bleeding episode averted (8,490 vs. 10,201 US dollars for scenario 1, 8,756 US dollars for scenario 3, and 12,459 US dollars for scenario 4) and per quality-adjusted life year (4,810 vs. 5,533 US dollars for scenario 1, 4,946 US dollars for scenario 3, and 5,876 US dollars for scenario 4). The high-dose intravenous PPI scenario was the dominant approach as evidenced by both superior effectiveness and lower costs over the range of probability and cost variables used in the sensitivity analysis. However, the dominance would be lost if the purchase cost of the intravenous PPI was substantially higher than the baseline cost assumed in this investigation (61 US dollars per 3-day course of therapy). CONCLUSION: High-dose intravenous PPI therapy in conjunction with therapeutic endoscopy is the most cost-effective approach for the management of hospitalized patients with acute peptic ulcer bleeding.     

Peptic ulcer: clinico-endoscopic and biochemical aspects of the development and healing of the peptic defect

The metabolism of collagen and glycoproteins bound with glycosaminoglycans was studied in 19 patients with a preulcerous condition (chronic primary gastroduodenitis) and in 49 patients with peptic ulcer of the stomach (12) and duodenum (37). The control groups comprised 12 practically healthy subjects (group I) and 20 patients with chronic secondary gastroduodenitis (group II). Based on the data obtained it is concluded that the high level of collagen metabolism in patients with chronic gastroduodenitis may be regarded as an early diagnostic criterion of the preulcerous condition. In patients with peptic ulcer, epithelization of the peptic defect controlled with the aid of studying the indicators of collagen formation should not be viewed as completed after clinico-endoscopic confirmation of the disease remission. There was a close correlation between the ulcerous crater area and the level of free hydroxyproline in gastric juice. High level of glycoproteins in patients with gastroduodenitis and peptic ulcer can be used as an additional criterion of the degree of the inflammatory reaction.     

Ulcers and nonvariceal bleeding

Peptic ulcer remains the commonest and most significant cause of nonvariceal upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding is rising in elderly patients, particularly for duodenal ulcer. Patients presenting with upper gastrointestinal bleeding who have low Rockall scores are at low risk of rebleeding and death. These patients currently utilize considerable health-care resources, but could safely be managed at home. The Rockall score can be used to predict the risk of rebleeding and death following variceal bleeding, but for patients with ulcer bleeding, its ability to predict death is questioned. Acid suppression is effective in preventing rebleeding from peptic ulcer. Standard doses of intravenous omeprazole may be as effective as high-dose regimens. Oral omeprazole also reduces rebleeding following endoscopic therapy for peptic ulcer. Mallory-Weiss tears result in significant bleeding in 23 % of cases. Endoscopic therapy may only be required in cases in which active bleeding is present. Endoscopic therapy is effective and safe in patients with major peptic ulcer bleeding who are over 80 years old. For peptic ulcer, injection of larger volumes of epinephrine (adrenaline; mean 16.5 ml) are more effective than small volumes (mean 8 ml). Injection of normal saline alone is less effective than bipolar electrocoagulation. The addition of fibrin glue to epinephrine injection does not confer an additional benefit over epinephrine alone. Argon plasma coagulation can be used to treat a range of lesions in the gastrointestinal tract. It is also effective for treatment of bleeding ulcer, but is no better than established methods. Haemoclips may be useful in bleeding Mallory-Weiss tears, but their use is difficult in patients bleeding from peptic ulcer. The presence of a large ulcer and active bleeding at the time of endoscopy are independent predictors of failure of endoscopic therapy.     

内镜下尼龙圈套扎治疗消化性溃疡大出血的临床观察及护理

目的探讨内镜下尼龙圈套扎对消化性溃疡大出血的治疗价值及护理。方法对37例消化性溃疡大出血患者采用内镜下尼龙圈套扎止血,术后密切观察病情及合理的饮食护理。结果37例消化性溃疡大出血病人,36例即时止血成功,且无复发出血及穿孔。结论尼龙圈套扎是一种安全有效的内镜下治疗消化性溃疡大出血的方法,高质量的术前术后护理是手术成功的重要因素之一,耐心细致的健康教育是防止复发的重要环节之一。     

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims: Patients suffering from peptic ulcer (PU) bleeding who have end‐stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis. Methods: A total of 540 patients with PU bleeding after initial endoscopic haemostasis in a tertiary hospital were investigated retrospectively. They were sorted into three groups after randomised age‐matched adjustment: ESRD group (n = 90), CKD group (n = 90) and control group (n = 360). Main outcome measurements were rebleeding, requirement for blood transfusion and surgery, length of hospital stay and mortality. Results: The rebleeding rates were 43% for the ESRD group vs. 21% for the CKD group vs. 12% for the control group (overall p = < 0.001). Multivariate analysis showed the predictors of rebleeding were ESRD, time to endoscope, and non‐high‐dose proton‐pump inhibitors (PPI) users. The risk factors for bleeding‐related mortality were presence of moderate degree of CKD and ESRD group, time to endoscope, and Rockall score. All‐cause mortality was related to presence of moderate degree of CKD and ESRD group, platelet count, time to endoscope, Rockall score and length of hospital stay. Conclusions: ESRD patients who suffered from PU bleeding were at risk of excessive rebleeding and mortality with frequent occurrence of delayed rebleeding. This study suggests that early endoscopy for initial haemostasis and high‐dose intravenous PPI are associated with the reduction of rebleeding risk especially in patients with high Rockall scores.     

Prevention of anti-inflammatory drug-induced gastrointestinal damage: benefits and risks of therapeutic strategies

Patients who take non-steroidal anti-inflammatory drugs (NSAIDs) may develop serious gastrointestinal (GI) side effects in both the upper and lower GI tract. Those at risk should be considered for prevention with misoprostol, proton pump inhibitor (PPI) or COX-2 selective inhibitor (coxib) therapy. A coxib or an NSAID+PPI combination is considered to have comparable GI safety profiles, but evidence from direct comparison is limited. PPIs are effective in the prevention of upper GI events in endoscopy trials and in a few, small, outcome trials in patients at risk. Coxibs have been evaluated in endoscopic ulcer studies and clinical outcome trials, and shown to significantly reduce the risk of upper GI ulcer and complications. Moreover, unlike PPIs, coxibs significantly reduce toxicity in the lower GI tract compared with NSAIDs. Coxibs and possibly some NSAIDs also increase the risk of developing serious cardiovascular events, an effect which may depend on the drug, dose and duration of therapy. It is not known whether concomitant low-dose aspirin use, which occurs in more than 20% of patients, will reduce the incidence of cardiovascular events, although concomitant aspirin increases the risk of developing serious GI events in patients taking either an NSAID or a coxib. Such patients may require additional PPI co-therapy. Current prevention strategies with an NSAID+PPI, misoprostol or a coxib must be considered in the individual patient with GI and cardiovascular risk factors. A PPI+coxib is indicated in those at highest risk (e.g. previous ulcer bleeding). PPI therapy must be considered for the treatment and prevention of NSAID-induced dyspepsia.     

��pid��miologie, ��tiologie et ��volution des h��morragies digestives hautes au centre hospitalier universitaire de F��s, Maroc

Background

Acute upper gastrointestinal bleeding (AUGIB) is a common emergency in hepatogastro-enterology. Epidemiology of AUGIB in our country remains unknown. The aim of this study is to evaluate the clinical and etiological characteristics and outcomes of patients with upper gastrointestinal bleeding and to define risk factors of poor prognosis.

Materials and methods

This is a retrospective (2001?C2004) and prospective (2005?C2008) study, including patients with AUGIB who had upper digestive endoscopy in Hassan II University Hospital of Fez.

Results

Thousand three hundred and three cases were included. Eight hundred and twenty-seven were men (63.5%). The mean age was 47.6 ± 17.7 years. The most common causes of AUGIB were ulcer bleeding (46%) and bleeding related to portal hypertension (PH) (23.3%). Prevalence of esophagitis and acute gastritis were 10.9% and 7.3% respectively. The recurrence rate and in-hospital mortality were 8.3% and 6.5% respectively. Portal hypertension-related bleeding, malignancy, advanced age, shock and recurrent bleeding were the main risk factors of mortality in our study.

Conclusion

The patients in our study were young. The most common etiology of AUGIB in our context was ulcer bleeding, which reflects the prevalence of peptic ulcer in our population. Portal hypertension-related bleeding, advanced age and recurrent bleeding were the main risk factors of mortality.     

Prevention of anti‐inflammatory drug‐induced gastrointestinal damage: Benefits and risks of therapeutic strategies

Patients who take non‐steroidal anti‐inflammatory drugs (NSAIDs) may develop serious gastrointestinal (GI) side effects in both the upper and lower GI tract. Those at risk should be considered for prevention with misoprostol, proton pump inhibitor (PPI) or COX‐2 selective inhibitor (coxib) therapy. A coxib or an NSAID+PPI combination is considered to have comparable GI safety profiles, but evidence from direct comparison is limited. PPIs are effective in the prevention of upper GI events in endoscopy trials and in a few, small, outcome trials in patients at risk. Coxibs have been evaluated in endoscopic ulcer studies and clinical outcome trials, and shown to significantly reduce the risk of upper GI ulcer and complications. Moreover, unlike PPIs, coxibs significantly reduce toxicity in the lower GI tract compared with NSAIDs. Coxibs and possibly some NSAIDs also increase the risk of developing serious cardiovascular events, an effect which may depend on the drug, dose and duration of therapy. It is not known whether concomitant low‐dose aspirin use, which occurs in more than 20% of patients, will reduce the incidence of cardiovascular events, although concomitant aspirin increases the risk of developing serious GI events in patients taking either an NSAID or a coxib. Such patients may require additional PPI co‐therapy. Current prevention strategies with an NSAID+PPI, misoprostol or a coxib must be considered in the individual patient with GI and cardiovascular risk factors. A PPI+coxib is indicated in those at highest risk (e.g. previous ulcer bleeding). PPI therapy must be considered for the treatment and prevention of NSAID‐induced dyspepsia.