Trends in acute nonvariceal upper gastrointestinal bleeding in dialysis patients

Impaired kidney function is a risk factor for upper gastrointestinal (GI) bleeding, an event associated with poor outcomes. The burden of upper GI bleeding and its effect on patients with ESRD are not well described. Using data from the US Renal Data System, we quantified the rates of occurrence of and associated 30-day mortality from acute, nonvariceal upper GI bleeding in patients undergoing dialysis; we used medical claims and previously validated algorithms where available. Overall, 948,345 patients contributed 2,296,323 patient-years for study. The occurrence rates for upper GI bleeding were 57 and 328 episodes per 1000 person-years according to stringent and lenient definitions of acute, nonvariceal upper GI bleeding, respectively. Unadjusted occurrence rates remained flat (stringent) or increased (lenient) from 1997 to 2008; after adjustment for sociodemographic characteristics and comorbid conditions, however, we found a significant decline for both definitions (linear approximation, 2.7% and 1.5% per year, respectively; P<0.001). In more recent years, patients had higher hematocrit levels before upper GI bleeding episodes and were more likely to receive blood transfusions during an episode. Overall 30-day mortality was 11.8%, which declined significantly over time (relative declines of 2.3% or 2.8% per year for the stringent and lenient definitions, respectively). In summary, despite declining trends worldwide, crude rates of acute, nonvariceal upper GI bleeding among patients undergoing dialysis have not decreased in the past 10 years. Although 30-day mortality related to upper GI bleeding declined, perhaps reflecting improvements in medical care, the burden on the ESRD population remains substantial.     

Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients

BACKGROUND: The risk of upper gastrointestinal bleeding (UGIB) is increased among end-stage renal disease (ESRD) patients compared to the general population. However, correlates of UGIB among ESRD patients remain unknown. We conducted a cohort study of dialysis patients to ascertain risk factors for UGIB. METHODS: Data from the United States Renal Data System Dialysis Morbidity and Mortality Studies, Waves 2-4 were used to identify risk factors for incident UGIB among ESRD patients. First hospitalizations for UGIB were identified using hospital diagnosis codes between 12/31/93 and 12/31/99. Cox regression was used to estimate the association between predictors of interest and first diagnosis of UGIB. RESULTS: Cases of UGIB (698) were observed over 30648 patient years of follow-up. Before adjustment for confounding factors, increasing age, diabetes, former and current smoking, cardiovascular disease (CVD), lower serum albumin, malnutrition, and inability to ambulate independently were associated with an increased risk of UGIB, while African Americans and transplant patients had a lower risk of UGIB. After adjustment, African American race was associated with a lower risk of UGIB (RR = 0.90; 0.82, 0.98), while current smoking (RR = 1.11; confidence interval 1.03, 1.19), history of CVD (RR = 1.32; 1.10, 1.59), and inability to ambulate independently (RR = 1.32; 1.07, 1.63) were associated with a higher risk of UGIB. Age, gender, diabetes, lower serum albumin, nourishment, treatment modality, aspirin use, nonsteroidal anti-inflammatory drug (NSAID) use, and antiplatelet or anticoagulant medication use were not found to be significantly related to the risk of UGIB after adjustment for potential confounding factors. CONCLUSION: CVD, current smoking, and risk factors suggesting more disability are associated with a greater risk of UGIB among patients with ESRD.     

Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding

The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 (22%). Contrast extravasation at angiography was seen in 25 of 64 patients (39%), and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3). Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 38%). Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., "blind" embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.     

Current therapy for nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding continues to plague physicians despite the discovery of Helicobacter pylori and advances in medical therapy for peptic ulcer disease. Medical therapy with new nonsteroidal anti-inflammatory medications and somatostatin/octreotide and intravenous proton pump inhibitors provides hope for reducing the incidence of and treating bleeding peptic ulcer disease. Endoscopic therapy remains the mainstay for diagnosis and treatment of upper gastrointestinal bleeding. Many methods of endoscopic hemostasis have proven useful in upper gastrointestinal hemorrhage. Currently, combination therapy with epinephrine injection and bicap or heater probe therapy is most commonly employed in the United States. Angiography and embolization play a role primarily when endoscopic therapy is unsuccessful.     

上消化道大出血患者的输液项目管理

对62例上消化道大出血抢救患者加强输液单项管理,包括早期诊断、迅速建立静脉输液通道,密切观察血流动力学变化、合理控制输液速度,根据药物作用及时效选择合适的输液通路.结果60例经补液、输血、止血治疗,血压稳定后行急诊胃镜检查治疗,60例治愈出院,2例抢救无效死亡.提示对上消化道大出血进行输液管理,能有效补充患者血容量,赢得抢救时间,提高治疗效果.     

Endoscopic control of upper gastrointestinal bleeding

One important objective in managing patients with upper gastrointestinal hemorrhage is to control the bleeding until the patient's condition is stable and definitive therapy can be carried out. Endoscopic techniques are now available to attain this goal. Endoscopic sclerosis has become an accepted treatment for bleeding esophageal varices, especially in patients with Child's class B or C cirrhosis. Control of nonvariceal bleeding by endoscopic techniques is now feasible and involves laser photocoagulation and electrocoagulation. Clinical experience with endoscopic laser photocoagulation has demonstrated that it can successfully arrest bleeding in gastric and duodenal ulcers. Endoscopic electrocoagulation has been successful in stopping bleeding from Mallory-Weiss tears, acute gastric erosions, and gastric, duodenal and stomal ulcers. Use of an endoscopic heater probe, now in the development stage, to control bleeding gastric and duodenal ulcers will be an important addition.     

Efficiency criteria for endoscopic diagnostic in upper gastrointestinal bleeding

Endoscopy plays a major role in the evaluation of upper digestive haemorrhage. We evaluate the difficulties in the introduction of emergency endoscopy in a period of transition, regarding mentalities and errors generated by the learning curve. The study includes 512 consecutive patients admitted with upper gastrointestinal haemorrhage. We retrospectively evaluate some proposed efficiency criteria for the diagnostic endoscopy: the frequency of incomplete endoscopic evaluation (14%), frequency and causes of endoscopic diagnostic errors (3%), frequency of upper digestive haemorrhages with no detectable source (24.2%) and the indication of multiple endoscopic examination. We discuss the causes responsible for the generation of such problems as well as the dynamics of those during the evaluated period.     

Management of acute upper gastrointestinal bleeding in a district hospital

BACKGROUND: This study was conducted to assess the management of acute upper gastrointestinal bleeding in a district hospital and to compare these results with national guidelines and the published literature. MATERIALS AND METHODS: This prospective and retrospective study included 112 patients, mean age 66 years, who presented with acute upper gastrointestinal bleeding between July 2004 and February 2005. All patients were assigned a Rockall risk assessment score. RESULTS: The surgical on-call teams managed all the patients according to an agreed protocol. Forty-nine patients had a Rockall score > or =4. Endoscopy was performed in all patients, with 60% accomplished within the first 24 hours. The most common cause found was peptic ulcer (30%). Therapeutic endoscopy was undertaken in 10 patients (9%) with a success rate of 70%. Open surgery was performed in 3 patients. One patient died after having surgery and the Rockall score was >5. Of the patients admitted with acute upper gastrointestinal bleeding, 90.2% were discharged without complication. Eleven patients died (9.8%) and all of them from the high risk group with Rockall scores > or =5. Their mean hospital stay was 17.8 days (range, 2-43 days). CONCLUSION: High-standard results in acute upper gastrointestinal bleeding can be achieved in a district hospital. The management, including the use of the operating theater facilities with operative and anesthetic support, was safe and efficient. A 24-hour-a-day endoscopy service is important to achieve early diagnosis and to plan management. A protocol and early endoscopy improve clinical outcome and reduce mortality, which occurred mostly among elderly patients with high risk scores. It is advisable to introduce the Rockall scoring system in practice.     

Surgical treatment of non-variceal upper gastrointestinal bleeding: our experience with 1482 patients

We retrospectively evaluated the medical records of patients admitted to the U.O.C. of General and Emergency Surgery with Surgical and Polyspecialistic Observation of the Emergency Unit of A.O.R.N. A. Cardarelli of Naples for non-variceal upper gastrointestinal bleeding from 2003 to 2006. All data regarding patients submitted to surgery for non-variceal upper gastrointestinal bleeding were collected including the number of patients submitted to surgery after failure of the endoscopic procedure, the diseases most frequently requiring surgery, the endoscopic and surgical procedures most frequently used, and the reasons that prompted the surgical procedure. Of 1482 patients admitted for non-variceal upper gastrointestinal bleeding the lesions that most frequently required surgery were peptic ulcer disease complicated by bleeding in 31 patients (70.5%) and cancer in 13 (29.5%). The most frequent surgical procedure was subtotal gastrectomy (17 patients [38.6%]), followed by direct haemostasis of the ulcer (13 patients [29.5%]), total gastrectomy (11 patients [25%]), and ulcer excision (3 patients [6.9%]). Subtotal or total gastrectomy is the surgical procedure of choice in patients with non-variceal upper gastrointestinal bleeding after failure of endoscopic treatment. The indication for gastrectomy should be determined on the basis of the patient's haemodynamic condition.     

Risk of massive upper gastrointestinal bleeding in gastric bypass patients taking clopidogrel

BACKGROUND: The antiplatelet drug clopidogrel (Plavix) is widely used in patients who have undergone coronary artery stenting or had a stroke. Because morbid obesity is associated with atherosclerosis, some of these patients are candidates for weight loss surgery. We chose to determine the risk of upper gastrointestinal bleeding after gastric bypass in patients taking clopidogrel. METHODS: Patients who took clopidogrel after gastric bypass were identified by specific review of the subset of patients who had had upper gastrointestinal bleeding requiring hospital admission and transfusion. All who bled underwent emergency endoscopy. RESULTS: Of 11 patients taking clopidogrel, 4 (36%) presented with significant upper gastrointestinal bleeding 25-234 days after gastric bypass. All stopped bleeding with discontinuation of the drug and treatment with an intravenous proton pump inhibitor. CONCLUSION: Gastric bypass patients appear to be at high risk of bleeding complications when taking clopidogrel. On the basis of the available published data from another high-risk group (i.e., those with a history of peptic ulcer disease), co-treatment with omeprazole may be indicated when clopidogrel must be continued.     

A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding

We have assessed the value of the BICAP electrocoagulation probe in reducing the incidence of further bleeding in patients with upper gastrointestinal haemorrhage. One hundred and twenty-nine patients were studied in a prospective randomized controlled trial. There were 85 male and 44 female patients, age range 16-92 years. Forty-five patients had stigmata of recent haemorrhage (visible vessel or spot) and were randomized during endoscopy to 24 control and 21 treatment patients. Seven control patients rebled compared with nine treated patients (Fisher's exact probability test P = 0.44). The transfusion requirements of control patients (3.9 +/- 3.2 units) was not different from that of treated patients (5.7 +/- 3.7 units): Mann Whitney U test, P = 0.06. In the treatment group there was no difference in the operation rate. Also, the number of probe applications between patients with further bleeding and those with no further bleeding was similar (11.6 +/- 5.5 and 11.0 +/- 5.75 respectively). Access with the probe was considered inadequate in 50 per cent of lesions, but this did not correlate with the incidence of rebleeding. Stigmata of recent haemorrhage were significant in predicting rebleeding (P = 0.0019 Fisher's exact probability test). Overall mortality rate of 3.2 per cent was low and was not influenced by electrocoagulation or presence of stigmata of recent haemorrhage. We have not shown that BICAP bipolar electrocoagulation reduces the incidence of rebleeding in upper gastrointestinal haemorrhage.     

Endoscopic Nd:YAG laser therapy in upper gastrointestinal bleeding

Between 1983 and 1986 thirty-seven patients with upper gastrointestinal bleeding or stigmata of acute bleeding were treated at the Second Department of Surgery with endoscopic laser therapy. The non-contact method was used. The cause of bleeding was gastric ulcer in 13 cases and duodenal ulcer in 5. Two patients had anastomotic ulcer, 6 had a simple ulcer, 7 had telangiectases (Mb. Osler), 2 had Mallory Weiss tears and 2 bled after gastric biopsy. Twenty-one patients bled during endoscopy and 16 had signs of recent bleeding. During acute bleeding laser treatment was effective in 95% (1, 3). However, 41% of all patients (15/37) rebled within a week after laser therapy and in 30% (11/37) an emergency operation was necessary. The overall mortality rate was 10.8% (4/37). Endoscopic laser coagulation is successful in the initial treatment of acute upper GI-bleeding. However, there is a considerable risk of rebleeding. Acute laser therapy may change an emergency operation into an elective one, provided that the group at risk of rebleeding can be anticipated at first endoscopy.     

Current management of upper gastrointestinal bleeding.

Over a four-year period, 585 patients were hospitalized for massive upper gastrointestinal bleeding. Endoscopy diagnosed the cause of bleeding in 80% of 200 patients so studied. Selective angiography localized the bleeding site in 12 of 20 patients, and infusion of vasopressor stopped hemorrhage in six. Barium studies was 90% accurate in diagnosing ulcer disease but failed to detect gastritis. One hundred thirty (22%) patients were operated upon for medically uncontrolled bleeding. The proportion of patients requiring surgery fell from 33% in year one to 13% in year four. Benign ulcer disease caused bleeding in 51% of surgical patients, while gastritis was found in 20%, esophageal varices in 15% and stress ulcer in 8%. Overall operative mortality was 29%. Among 38 duodenal ulcer patients, mortality was 18%. Vagotomy and pyloroplasty were more effective than resection in this group. Resection for distal gastric ulcers in 22 patients resulted in a mortality of 14% and no rebleeding. While V&P controlled bleeding in 12 alcoholics with gastritis, five (42%) died postoperatively. Mortality among 20 patients with esophageal varices was 35%, although all five survived who had porto-caval shunts. Eight of 10 patients operated upon for stress ulcer bleeding died. Postoperative rebleeding occurred in 14 patients, eight of whom were again operated upon. In all but one a new lesion was found to be responsible for hemorrhage. Increasing use of gastroscopy and selective angiography can be expected to improve diagnostic capabilities in patients with upper gastrointestinal bleeding. Infusing vasopressor into selected arteries should reduce the need for surgical control of gastritis, variceal and stress ulcer bleeding, conditions poorly managed by current operative techniques.     

Massive upper gastrointestinal bleeding. Data on 369 surgically treated patients

An analysis of 369 patients operated on for massive upper gastrointestinal bleeding is presented. Gastroscopy was performed in all patients. Duodenal ulcer remains the most common cause of such bleeding (45.4 percent of cases). The type of treatment that should be used is the most controversial in patients with bleeding esophageal varices. It is concluded that the procedure that corrects the patient's primary disease is also the most suitable one for treating massive bleeding.