Second look endoscopy in acute non-variceal upper gastrointestinal bleeding

Bleeding peptic ulcer remained an important cause of hospitalization worldwide. Primary endoscopic hemostasis achieved more than 90% of initial hemostasis for bleeding peptic ulcer. Recurrent bleeding amounted to 15% after therapeutic endoscopy, and rebleeding is an important risk factor to peptic ulcer related mortality. Routine second look endoscopy was one of the strategies targeted at prevention of rebleeding. The objective of second look endoscopy was to treat persistent stigmata of recent hemorrhage before rebleeding. Three meta-analyses showed that performance of routine second look endoscopy significantly reduced ulcer rebleeding especially when the endoscopic therapy was performed with thermal coagulation. Two cost-effectiveness analyses, however, demonstrated that selective instead of routine second look endoscopy is the most cost-effective approach to prevent ulcer rebleeding. While international consensus and guidelines did not recommend routine performance of second look endoscopy for prevention of ulcer rebleeding, further research should focus on identification of patients with high risk of rebleeding and investigate the effect of selective second look endoscopy in prevention of rebleeding among these patients.     

Rockall score in predicting outcomes of elderly patients with acute upper gastrointestinal bleeding

AIM: To validate the clinical Rockall score in predicting outcomes (rebleeding, surgery and mortality) in elderly patients with acute upper gastrointestinal bleeding (AUGIB). METHODS: A retrospective analysis was undertaken in 341 patients admitted to the emergency room and Intensive Care Unit of Xuanwu Hospital of Capital Medical University with non-variceal upper gastrointestinal bleeding. The Rockall scores were calculated, and the association between clinical Rockall scores and patient outcomes (rebleeding, surgery and mortality) was assessed. Based on the Rockall scores, patients were divided into three risk categories: low risk ≤ 3, moderate risk 3-4, high risk ≥ 4, and the percentages of rebleeding/death/surgery in each risk category were compared. The area under the receiver operating characteristic (ROC) curve was calculated to assess the validity of the Rockall system in predicting rebleeding, surgery and mortality of patients with AUGIB. RESULTS: A positive linear correlation between clinical Rockall scores and patient outcomes in terms of rebleeding, surgery and mortality was observed (r =0.962, 0.955 and 0.946, respectively, P = 0.001). High clinical Rockall scores > 3 were associated with adverse outcomes (rebleeding, surgery and death). There was a significant correlation between high Rockall scores and the occurrence of rebleeding, surgery and mortality in the entire patient population (χ 2 = 49.29, 23.10 and 27.64, respectively, P = 0.001). For rebleeding, the area under the ROC curve was 0.788 (95%CI: 0.726-0.849, P = 0.001); For surgery, the area under the ROC curve was 0.752 (95%CI: 0.679-0.825, P = 0.001) and for mortality, the area under the ROC curve was 0.787 (95%CI: 0.716-0.859, P = 0.001). CONCLUSION: The Rockall score is clinically useful, rapid and accurate in predicting rebleeding, surgery and mortality outcomes in elderly patients with AUGIB.     

急性非静脉曲张性上消化道出血内镜止血成功后再出血的危险因素分析

目的探讨急性非静脉曲张性上消化道出血（ANVUGIB）首次内镜止血成功后再出血的危险因素。方法回顾ANVUGIB首次内镜止血成功患者316例,按3d内是否再出血分为再出血组（n=80）和无再出血组（n=236）,对比两组患者临床及辅助检查资料、内镜下表现、内镜治疗及后续治疗等变量的差异。单因素X^2检验选出差异有统计学意义的因素,并以之为自变量,是否再出血为因变量,行多因素Logistic回归分析,寻找再出血的危险因素。结果两组患者恶性肿瘤出血、抑酸药使用、血红蛋白、入院时休克、病灶喷射样出血、支持治疗情况、内镜治疗方法等差异有统计学意义（P〈0．05）。经向后删除法Logistic回归分析,保留在模型中的变量有单一方法内镜治疗（OR=5．383）、恶性肿瘤出血（OR=4．812）、无后续PPIs（OR=4．351）、HGB〈90g／L（OR=4．342）、病灶喷射样出血（OR=4．320）、支持治疗不足（OR=3．271）,其95％CI下限均大于1。结论单一方法内镜治疗、恶性肿瘤出血、无后续PPIs、血色素低、病灶喷射样出血、支持治疗不足是ANVUGIB首次内镜止血成功后再出血的危险因素。     

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: A meta-analysis

Abstract

Objective. Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. Materials and methods. Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). Results. Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85–8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24–0.74, p < 0.01), and a trend for less units of blood transfused (WMD ?0.48; 95% CI ?0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. Conclusions. Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.     

完整Rockall和临床Rockall危险评分对老年急性非静脉曲张上消化道出血评估价值

目的 探讨完整和临床Rockall评分对老年急性非静脉曲张上消化道出血患者输血、再出血、干预和死亡的预测价值.方法 采用完整和临床Rockau评分系统对老年急性非静脉曲张上消化道出血患者进行危险程度分级,并与同期非老年组比较,应用ROC曲线评估两个评分系统的预测价值.结果 随着评分增加,老年临床高危患者所占比例逐渐增加,两者呈正相关（P＜0.05）.完整Rockall评分对老年患者输血、再出血、干预和死亡均有较好的预测价值,受试者工作特征曲线下面积AUC值分别为0.67、0.84、0.70和0.96（P ＜0.01）;临床Rockall评分对老年患者输血、再出血和死亡有较好的预测价值,AUC值分别为0.66、0.79和0.91（P ＜0.01）,对干预无预测价值（P＞0.05）.结论 老年急性非静脉曲张上消化道出血患者可用较为简单的临床Rockall评分预测输血、再出血和死亡风险.     

Effects of acute kidney injury on acute pancreatitis patients’ survival rate in intensive care unit: A retrospective study

BACKGROUNDAcute kidney injury (AKI) is one of the most common acute pancreatitis (AP)-associated complications that has a significant effect on AP, but the factors affecting the AP patients’ survival rate remains unclear.AIMTo assess the influences of AKI on the survival rate in AP patients. METHODSA total of 139 AP patients were included in this retrospective study. Patients were divided into AKI group (n = 72) and non-AKI group (n = 67) according to the occurrence of AKI. Data were collected from medical records of hospitalized patients. Then, these data were compared between the two groups and further analysis was performed.RESULTSAKI is more likely to occur in male AP patients (P = 0.009). AP patients in AKI group exhibited a significantly higher acute physiologic assessment and chronic health evaluation II score, higher Sequential Organ Failure Assessment score, lower Glasgow Coma Scale score, and higher demand for mechanical ventilation, infusion of vasopressors, and renal replacement therapy than AP patients in non-AKI group (P < 0.01, P < 0.01, P = 0.01, P = 0.001, P < 0.01, P < 0.01, respectively). Significant differences were noted in dose of norepinephrine and adrenaline, duration of mechanical ventilation, maximum and mean values of intra-peritoneal pressure (IPP), maximum and mean values of procalcitonin, maximum and mean serum levels of creatinine, minimum platelet count, and length of hospitalization. Among AP patients with AKI, the survival rate of surgical intensive care unit and in-hospital were only 23% and 21% of the corresponding rates in AP patients without AKI, respectively. The factors that influenced the AP patients’ survival rate included body mass index (BMI), mean values of IPP, minimum platelet count, and hospital day, of which mean values of IPP showed the greatest impact.CONCLUSIONAP patients with AKI had a lower survival rate and worse relevant clinical outcomes than AP patients without AKI, which necessitates further attention to AP patients with AKI in surgical intensive care unit.     

急诊胃镜诊治急性上消化道非曲张静脉破裂出血42例

目的:观察注射肾上腺素及热探头凝固疗法对上消化道非曲张静脉破裂出血的治疗作用.方法:对42例上消化道活动性出血患者(13例胃溃疡,25例十二指肠球部溃疡,4例Dieulafoy's病)进行局部注射肾上腺素及热探头凝固治疗.结果:42例患者经首次治疗后,有38例(90.5%)出血停止(消化性溃疡35/38,Dieulafoy's病3/4),再出血率为23.7%(9/38).手术率为19.0%(8/42),无死亡发生.结论:局部注射肾上腺素及热探头凝固法是治疗上消化道非静脉曲张破裂出血的有效手段.     

急性上消化道出血Rockall评分系统的应用及与预后的关系

[目的]探讨急性上消化道出血（AUGIB）患者Rockatl危险性积分的应用及其与预后的关系。[方法]114例于2011年2月至2013年2月间接诊的AUGIB患者进行Rockall危险性积分评分,并分为低危组（≤2分）、中危组（3～4分）和高危组（≥5分）,比较住院期间及电话随访出院30天内各组患者输血、再出血和死亡事件发生率差异。[结果]114例患者中,列入低危组29例（25．44％）、中危组45例（37．47％）、高危组40例（35．09％）;低危组、中危组、高危组输血率分别为3．45％、24．44％、42．50Yoo（组间比较X2=13．56,P〈0．01）,再出血率分别为6．89％、15．56％、30．00％（组间比较X2=6．38,P〈O．05）,病死率分别为0％、2．22％、15．00％（组间比较X2=25．67,P〈0．001）,组间比较均差异有统计学意义。[结论]Rockall危险性积分对AUGIB患者预后有较强预测价值,适合作为判断AUGIB预后和制定治疗措施的依据。     

Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study

Objective: Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care. Material and methods: This population-based cohort study included all emergency EGDs for PUB in adults during 2012–2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model. Results: Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR?=?1.51 (95% CI?=?1.25–1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR?=?1.22 (95% CI?=?0.55–2.71). The prevalence of anaesthesia care varied between the hospitals, median?=?78.9% (range 6.9–98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity. Conclusions: Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.     

Acute upper gastrointestinal bleeding in octogenarians： Clinical outcome and factors related to mortality

AIM： To evaluate the aetiology, clinical outcome and factors related to mortality of acute upper gastrointestinal bleeding （AUGIB） in octogenarians.
METHODS： We reviewed the records of all patients over 65 years old who were hospitalised with AUGIB in two hospitals from January 2006 to December of 2006. Patients were divided into two groups： Group A （65-80 years old） and Group B （〉 80 years old）. RESULTS： Four hundred and sixteen patients over 65 years of age were hospitalized because of AUGIB. Group A included 269 patients and Group B 147 patients. Co-morbidity was more common in octogenarians （P = 0.04）. The main cause of bleeding was peptic ulcer in both groups. Rebleeding and emergency surgery were uncommon in octogenarians and not different from those in younger patients. In-hospital complications were more common in octogenarians （P = 0.05） and more patients died in the group of octogenarians compared to the younger age group （P = 0.02）. Inability to perform endoscopic examination （P = 0.002）, presence of high risk for rebleeding stigmata （P = 0.004）, urea on admission （P = 0.036）, rebleeding （P = 0.004） and presence of severe co-morbidity （P 〈 0.0001） were related to mortality. In multivariate analysis, only the presence of severe co-morbidity was independently related to mortality （P = 0.032）.
CONCLUSION： While rebleeding and emergency surgery rates are relatively low in octogenarians with AUGIB, the presence of severe co-morbidity is the main factor of adverse outcome.     

Risk analysis of 30-day rebleeding in acute non-variceal upper gastrointestinal bleeding

Background and study aimsThis study aimed to compare the prognostic value of ABC, Glasgow-Blatchford, Rockall and AIMS65 scoring systems in predicting rebleeding rate within 30 days after endoscopic treatment of acute non-variceal upper gastrointestinal bleeding (ANVUGIB).Patients and methodsA total of 93 patients with ANVUGIB were selected as the study subjects and they were divided into groups according to whether there was rebleeding in the 30 days’ follow-up period. 7 patients with rebleeding within 30 days were included in the rebleeding group, and the other 86 patients without rebleeding were included in the non-rebleeding group.ResultsBy drawing ROC curve, we found that ABC scoring system had the highest accuracy (area under the receiver operating characteristic (AUROC) curve [95% confidence interval (CI), 0.65]) in predicting rebleeding within 30 days compared with the AIMS65 (0.56; P < 0.001), RS (0.51; P < 0.001), and GBS (0.61; P < 0.001). ABC scoring system showed the highest risk of rebleeding in 30 days. When the 4 scoring standards were judged as medium–high risk patients, the efficacy of the ABC scoring system in predicting the risk of rebleeding at 30 days for ANVUGIB was found to be the best in diagnostic sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy.ConclusionComprehensive evaluation showed that ABC score had the highest prediction accuracy. The negative differential significance of each evaluation method was great, that is, the risk of rebleeding was generally low when judged as low risk patients, while the value of predicting rebleeding was limited when judged as medium and high risk patients.     

Treatment with proton pump inhibitors in acute non-variceal upper gastrointestinal bleeding: a meta-analysis

Medical therapy is an attractive adjuvant to endoscopic treatment in upper gastrointestinal (UGI) bleeding. This review aims to assess the treatment effects of proton pump inhibitor (PPI) therapy in acute non-variceal UGI bleeding. Outcome measures evaluated were further bleeding, surgery, all-cause deaths, ulcer deaths and non-ulcer deaths. We searched MEDLINE (1966-2002) and EMBASE (1974-2002) using the terms 'gastrointestinal hemorrhage', 'peptic ulcer hemorrhage', 'proton pump inhibitor', 'omeprazole', 'pantoprazole', 'lansoprazole', 'rabeprazole' and 'esomeprazole'. The search was extended to the Cochrane controlled trials registry database, published abstracts from five international gastroenterology conferences, manufacturers of PPI, known contacts and bibliographies from each full-length published report. We included trials published in English and non-English languages. Eligible studies were randomized controlled trials that compared the treatment effects of PPI therapy with placebo or H2 receptor antagonists in patients with acute non-variceal UGI bleeding. Of the 175 articles screened, 26 controlled trials including 4670 subjects (2317 in treatment arm and 2353 in control arm) were analyzed. The methodology, population, intervention, and outcomes of each selected trial were evaluated using duplicate independent review. Disagreements were resolved by consensus. PPI therapy significantly reduced rates of further bleeding (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40-0.57) and surgery (OR, 0.61; 95% CI, 0.48-0.76). All-cause deaths were unaffected (OR, 1.02; 95% CI, 0.76-1.37). Ulcer deaths showed a significant reduction (OR, 0.58; 95% CI, 0.35-0.96), while non-ulcer deaths showed a significant increase (OR, 1.60; 95% CI, 1.06-2.41) in the PPI therapy group. Sensitivity analysis of 22 trials published in peer-reviewed journals, 10 trials with double-blind design and 19 trials with high quality score and 22 trials using omeprazole in the treatment group showed results similar to those seen in the analysis of all 26 trials, confirming the stability of the conclusions. Subgroup analysis revealed that summary outcome measures were not influenced by control group therapy (placebo vs H2 receptor antagonists) or the use of prior endoscopic treatment to achieve hemostasis (given vs not given). However, the summary treatment effects for further bleeding and need for surgery were significant in only those trials enrolling patients with peptic ulcers having high risk for rebleeding and not in those trials enrolling patients with all causes of UGI bleeding. The summary treatment effects for further bleeding and need for surgery were significant in trials using intravenous as well as oral PPI. However, summary OR for all-cause deaths and non-ulcer deaths in trials using intravenous PPI were higher in the treatment group and not in trials using oral PPI. This raised the possibility of intravenous PPI-therapy-associated non-ulcer deaths in high-risk patients. PPI therapy in acute non-variceal UGI bleeding reduced rates of further bleeding, surgery and deaths caused by ulcer complications. However, non-ulcer deaths were increased. The overall mortality was unaffected. PPI therapy is useful only in a selected group of patients with acute non-variceal UGI bleeding, namely those with peptic ulcers having endoscopic high-risk stigmata for rebleeding.     

Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1,044 consecutive patients

Background  Video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) enable the detection of small intestinal lesions. Aim  To examine causes of acute overt gastrointestinal (GI) bleeding and the prevalence of mid-GI bleeding, defined as small intestinal bleeding from the ampulla of Vater to the terminal ileum, in a multi-center experience in Japan in the VCE/DBE era. Methods  Data were collected retrospectively from consecutive patients with acute overt GI bleeding in ten participating hospitals. All patients were examined by esophagogastroduodenoscopy and/or colonoscopy. When the source of bleeding was not identified after these procedures, patients suspected to have mid-GI bleeding were referred to our hospital and VCE/DBE was performed to determine the source of bleeding. Results  Of the 1044 patients with acute overt GI bleeding, 524 (50.2%) patients were diagnosed with upper GI bleeding, 442 (42.3%) with lower GI bleeding, and 13 (1.2%) with mid-GI bleeding. Gastric ulcer was the most common cause of bleeding (20.4%). Among cases of mid-GI bleeding, ulcers were found in 4 (30.8%) patients, erosions in 3 (23.1%), angiodysplasia in 3 (23.1%), submucosal tumor in 2 (15.4%), and hemangioma in one (7.7%). Seven lesions were located in the jejunum, 5 in the ileum, and one in both the jejunum and ileum. Analysis of age-related cause showed that the prevalence of mid-GI bleeding among younger patients under 40 years of age was higher (5%) than in other age groups (1–2%). Conclusion  mid-GI bleeding is rare among Japanese patients with acute overt GI bleeding.     

Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes

Background Potent antiplatelet and anticoagulant agents along with early revascularization are increasingly used in patients hospitalized with acute coronary syndromes (ACS). An important complication associated with these therapies is gastrointestinal bleeding (GIB); yet, the predictors, optimal management, and outcomes associated with GIB in ACS patients are poorly studied. Methods We investigated the incidence, predictors, pathological findings, and clinical outcomes associated with GIB in patients with ACS hospitalized at a United States tertiary center between 1996 and 2001. Results Three percent (80/3,045) of ACS patients developed clinically significant GIB. Predictors of GIB were older age, female gender, non-smoking status, peak troponin I, and prior heart failure, diabetes, or hypertension. Patients with GIB were more critically ill with lower blood pressure and higher heart rates. GIB was associated with an increased need for transfusion, mechanical ventilation, and inotropes/pressors. In-hospital mortality was significantly higher in ACS patients with versus without GIB (36% vs. 5%, P < 0.001). Thirty patients (38%) with GIB underwent endoscopy with no procedural complications of death, arrhythmia, urgent ischemia, or hemodynamic deterioration. Conclusion In patients with ACS, GIB is associated with older age, female sex, peak troponin I, non-smoking status, diabetes, hypertension, and heart failure. Hospital mortality is increased eightfold when ACS patients experience GIB. More studies are needed to establish the safety of and optimal timing of endoscopy in these patients.     

双抗血小板聚集药物应用后患者急性非静脉曲张性上消化道出血的发生率、临床特点及相关因素分析

目的：探讨双抗血小板聚集药物所致急性非静脉曲张性上消化道出血（ANVUGIB）临床特点及相关因素。方法：以本院2010年3月～2015年12月接受双抗血小板聚集药物治疗的800例患者为研究对象,以6个月内ANVUGIB发生率为终点事件,单因素及Logistic多因素回归分析抗血小板聚集药物所致ANVUGIB发生相关因素。结果：双抗血小板聚集药物所致ANVUGIB发生率6.2%;首发表现为黑便者22例（44.0%）,呕血8例（16.0%）,呕血伴黑便者14例（28.0%）;轻度出血30例,中度出血10例,重度出血10例;胃镜检查者42例（84.0%）,出血位于胃部25例（59.5%）;Logistic多因素回归分析显示ANVUGIB发生独立危险因素包括年龄（＞60岁）、双抗血小板聚集用药时间（＞3个月）、既往上消化道出血史。结论：双抗血小板聚集药物所致ANVUGIB首发症状以黑便为主,好发于胃部,其发生与患者年龄、双抗血小板用药时间、既往上消化道出血史有关。