The utility of urgent colonoscopy in the evaluation of acute lower gastrointestinal tract bleeding: a 2-year experience from a single center

OBJECTIVE: Urgent colonoscopy is often recommended to evaluate acute rectal bleeding. However, it may not identify a source because of blood in the lumen or inadequate preparation. Our aim was to determine the utility of urgent colonoscopy as the initial test for acute rectal bleeding. METHODS: This was a retrospective chart review of all patients discharged in 1997 and 1998 with an International Classification of Diseases, 9th Revision, code for hematochezia or rectal bleeding. RESULTS: We identified 514 charts but excluded 424 because of inaccurate coding. In the 90 with confirmed acute rectal bleeding, colonoscopy was the initial test in 39; age, sex, and race distributions were similar to those who did not have colonoscopy. A definite source of bleeding was seen at colonoscopy in only three patients, a probable source in 26, and no source in 10. Therapeutic intervention in four patients with a definite or probable source was successful in three. The commonest reasons for not performing urgent colonoscopy were bleeding from presumed hemorrhoids or bleeding that was clinically insignificant. Spontaneous resolution of bleeding and length of hospital stay were not affected by urgent colonoscopy. Five patients had surgery for unrelated reasons. In-hospital mortality was 2% and was unrelated to bleeding. CONCLUSION: Urgent colonoscopy as the initial investigation in acute lower GI tract bleeding probably does not alter the outcome in most cases. Identification of a definite bleeding source leading to successful therapeutic intervention is rare. Spontaneous resolution is frequent, length of hospital stay is similar, and clinical outcome is excellent regardless of whether or not urgent colonoscopy is performed.     

Target Population of Non-deferrable Surgery and Uncontrolled Severe Bleeding Related to Dabigatran

Purpose

This observational study was aimed to identify patients who experienced non-deferrable surgery and/or uncontrolled severe bleeding following dabigatran administration and then are potentially eligible to the use of the specific antidote idarucizumab in a real-world setting.

Methods

From the big Italian real-world database ARCO, a cohort of adult patients treated with dabigatran and hospitalized due to diagnoses attributable to urgent interventions and/or major bleeding was selected in 2014. Baseline characteristics and all-cause hospitalizations, specialist/diagnostic outpatient services, and healthcare costs over the 1-year follow-up were described.

Results

Out of 16,756,843 Italian citizens, 271,540 (1.9%) were prescribed with oral anticoagulants, and specifically, 17,450 with dabigatran. Patients identified to be hospitalized for non-deferrable surgery (n?=?106) and/or uncontrolled severe bleeding (n?=?190) following dabigatran use were 289 (1.7%) [mean age (± SD) 79?±?7, 50% of female sex]. On average, patients stayed in hospital 13.7 and 17.0 days, respectively. The per patient and per year cost to the Italian National Health System was on average 19,708€ (specifically 1487€ for drugs, of which 311€ for dabigatran, 17,353€ for all-cause hospitalizations, and 869€ for outpatient care), about four times more than the mean healthcare integrated cost of a single patient treated with dabigatran (4775€).

Conclusions

This analysis of the ARCO database reliably describes the population potentially eligible to the dabigatran reversal agent, idarucizumab. These data may be useful for Healthcare Decision Makers to organize, define, and improve present and future emergency healthcare, mainly as starting point for cost-effectiveness analyses of new reversal agents.

     

Hetastarch and bleeding complications after coronary artery surgery

STUDY OBJECTIVES: Controversy persists concerning the potential association between intraoperative use of hetastarch (ie, hydroxyethyl starch [HES]) and postoperative bleeding in patients undergoing surgery. To determine whether intraoperative HES use is associated with an increased risk of postoperative bleeding following coronary artery bypass graft (CABG) surgery. DESIGN: Case-control study. SETTING: A large academic medical center in the northeastern United States. PARTICIPANTS: A consecutive sample of 238 patients undergoing CABG surgery. MAIN OUTCOME MEASURES: Cases consisted of patients who had received either > or = 3 U packed RBCs, > or = 3 U platelets, > or= 3 U fresh frozen plasma, or any cryoprecipitate within 72 h after undergoing a CABG procedure, or who had undergone surgical revision for bleeding. All other CABG surgery patients served as control subjects. RESULTS: In multivariate models that controlled for a wide variety of demographic and clinical characteristics, we found that, compared to patients who did not receive any HES during surgery, those who received 1 U intraoperative HES had more than twice the risk of a bleeding outcome (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.10 to 4.91), and those who received 2 or 3 U HES had more than four times the risk of postoperative bleeding (OR, 4.57; 95% CI, 1.74 to 12.00). CONCLUSIONS: HES use in patients undergoing CABG surgery may be associated with a significant risk of postoperative bleeding. A double-blinded, randomized, controlled trial will be necessary to confirm this finding.     

Assessment of patients post reversal with idarucizumab

Idarucizumab, a fully humanized Fab antibody fragment, is indicated for reversal of dabigatran’s anticoagulant activity. Idarucizumab neutralizes the anticoagulant effects of dabigatran by binding to dabigatran and its metabolite. In the full analysis of 503 patients, idarucizumab fully reversed the anticoagulant effect of dabigatran in more than 98% of patients. Real-world clinical experience with idarucizumab for dabigatran reversal remains limited. We report 11 real-world clinical cases in which idarucizumab was administered for dabigatran reversal in the setting of bleed (bleeding cohort n?=?5) or emergent procedure (emergent procedure cohort, n?=?6). Coagulation tests and clinical outcomes were assessed before and after idarucizumab administration. Clinical outcomes included thromboembolic events and hemostasis. The median (IQR) aPTT (seconds) before versus after idarucizumab was 40.4 (36.1) versus 27.3 (6.2) (bleeding cohort) and 50.1 (13.4) versus 26.5 (8.1) (emergent procedure cohort). The median (IQR) INR before and after idarucizumab was 2.0 (1.1) versus 1.2 (0.1) (bleeding cohort) and 1.1 (0.5) versus 1.1 (0.3) (emergent procedure cohort). Hemostasis was achieved in 4/5 patients in the bleeding cohort and 5/6 patients in the emergent procedure cohort. Thrombotic events occurred in four patients with a median time (IQR) from idarucizumab administration of 7.4 (4.3–14.7) days. Idarucizumab achieved adequate dabigatran reversal as evident by normalization of aPTT, INR, and achieving hemostasis. However, our data demonstrates a high thrombotic risk associated with dabigatran reversal with idarucizumab than previously reported.     

Reoperation, emergency and urgent open cardiac surgery in Jehovah's Witnesses.

Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah's Witnesses religious group to undergo open cardiac operations with remarkable safety. However, hospital mortality remains high in (1) patients requiring reoperation (in whom both technical and bleeding problems tend to be more frequent) and (2) patients with significantly compromised cardiac performance requiring urgent or emergency operation. Employing a number of perioperative measures designed to minimize blood loss and maintain hematocrit levels (including use of the recently available recombinant human erythropoietin in two patients whose cases are reported herein), 13 reoperations and five urgent or emergency operations were performed. The one death in the entire series occurred in a patient (reoperation group) who died of a cerebrovascular accident of presumed embolic etiology, having undergone combined debridement of a stenotic heavily calcified aortic valve and a second coronary artery revascularization procedure. None of the patients required surgical exploration for bleeding. We suggest that currently available methodology permits Jehovah's Witnesses to undergo reoperation, emergency surgery, or urgent open cardiac operation at a level of risk not dissimilar to that seen in patients who permit use of homologous blood and products in their treatment.     

Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: A position statement of the Canadian Cardiovascular Society

Acute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) during the index admission. Most studies show that patients who receive ASA and clopidogrel within five days of CABG have an increase in operative bleeding. Current consensus guidelines recommend discontinuation of clopidogrel therapy at least five days before planned CABG to reduce bleeding-related events. However, high-risk individuals may require urgent surgery without delay, to reduce the risk of potentially fatal ischemic events. The present multidisciplinary position statement provides evidence-based recommendations for the optimal use of dual antiplatelet therapy to balance ischemic and bleeding risks in patients with recent ACS who may require urgent CABG.

Recommendations:

1. All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG.
2. For patients who have received clopidogrel and ASA, and require CABG:
   • Those at high risk of an early fatal event (eg, with refractory ischemia despite optimal medical treatment, and with high-risk coronary anatomy (eg, severe left main stenosis with severe right coronary artery disease), should be considered for early surgery without discontinuation of clopidogrel.
   • In patients with a high bleeding risk (eg, previous surgery, complex surgery) who are also at high risk for an ischemic event, consideration should be given to discontinuing clopidogrel for three to five days before surgery.
   • Patients at a lower risk for ischemic events (most patients) should have clopidogrel discontinued five days before surgery.
3. For patients who have CABG within five days of receiving clopidogrel and ASA, the risk of major bleeding and transfusion can be minimized by applying multiple strategies before and during surgery.
4. Patients who receive clopidogrel pre-CABG for a recent ACS indication should have clopidogrel restarted after surgery to decrease the risk of recurrent ACS.
5. For patients with a recent coronary stent, the decision to continue clopidogrel until the time of surgery or to discontinue will depend on the risk and potential impact of stent thrombosis. Restarting clopidogrel after CABG will depend on whether the stented vessel was revascularized, the type of stent and the time from stent implantation. Clopidogrel should be restarted when hemostasis is assured to prevent recurrent acute ischemic events.

     

Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy

AIM: The aim was to determine whether the use of steroids, immunosuppressive agents, or infliximab prior to abdominal surgery for Crohn's disease is associated with an increased rate of early postoperative complications. METHODS: All patients who underwent abdominal surgery for Crohn's disease between October 1998 and December 2001 were identified. Medical records were abstracted for demographics, location and duration of disease, use of infliximab within 8 wk before and 4 wk after surgery, and dose and duration of corticosteroids, azathioprine/6-mercaptopurine, and methotrexate. Steroid use was defined as: high (intravenous or oral >/=40 mg/day), moderate (oral >/=20 mg/day for at least 2 months), low (oral <20 mg/day or oral >20 mg/day for <2 months), or none. Early (within 30 days postinfliximab) septic and nonseptic complications were identified. Septic complications included wound sepsis, intraabdominal, and extraabdominal infections. Nonseptic complications included Crohn's disease recurrence, small bowel obstruction, gastrointestinal bleeding, and thromboembolism. A logistic regression analysis assessed the association between perioperative therapy with infliximab, corticosteroids, or immunosuppressive therapy and subsequent occurrence of septic complications and separately overall complications. RESULTS: Two hundred and seventy patients were operated upon including 107 patients who received steroids (34 low dose, 34 moderate dose, 43 high dose), 105 patients who received immunosuppressives (64 azathioprine, 38 6-mercaptopurine, 4 methotrexate), and 52 who received infliximab. Forty-eight patients underwent urgent or emergent surgery and 222 underwent elective surgery. Septic complications occurred in 52 of 270 (19%) patients including wound sepsis in 28 (10%), anastomotic leak in 9 (3%), intraabdominal abscess in 5 (2%), and extraabdominal infections in 19 (7%). Nonseptic complications occurred in 18 of 270 (7%) patients. Preoperative use of high- or moderate-dose steroids, immunosuppressives, or infliximab was not associated with greater complication rates. No deaths occurred. CONCLUSION: Early complications after elective abdominal surgery for CD are not associated with steroid dose, immunosuppressive therapy, or infliximab use.     

Effects of continuous administration of clopidogrel before off-pump coronary artery bypass grafting in patients with acute coronary syndrome.

BACKGROUND: Clopidogrel has become standard treatment after urgent percutaneous coronary revascularization. Due to its enhanced and irreversible platelet inhibition, patients undergoing urgent surgical revascularization have a higher risk of bleeding complications and transfusions. Therefore, the effect of preoperative continuous administration of clopidogrel on the incidence of hemorrhagic complications in patients undergoing off-pump coronary artery bypass surgery with acute coronary syndrome was evaluated. METHODS AND RESULTS: From March 2004 to September 2006, 172 patients with acute coronary syndrome underwent isolated off-pump coronary artery bypass surgery; 70 (40.7%) and 102 (59.3%) of these patients did or did not take clopidogrel before surgery respectively. Seventy patients in each group were matched using propensity scores and associations between preoperative continuous administration of clopidogrel and postoperative bleeding, hemostatic reoperation, blood products received, the need for multiple transfusions and early graft patency by coronary computed tomography were assessed. Univariate analysis showed the continuous clopidogrel group had similar levels of postoperative bleeding for 24 h (601.4+/-312.6 ml vs 637.2+/-452.4 ml, p=0.616) and rates of reexploration (1.4% vs 1.4%), perioperative blood transfusion (33.3% vs 34.3%, p>0.05) and platelet transfusion (2.9% vs 7.1%, p=0.44) compared with the non-continuous group. CONCLUSIONS: Preoperative continuous administration of clopidogrel did not increase the risk of hemorrhagic complications in patients with acute coronary syndrome undergoing isolated off-pump coronary artery bypass surgery. These findings indicate that surgery after clopidogrel treatment in patients with acute coronary syndrome should not be delayed until platelet function returns to normal because they may have a higher risk of recurrent myocardial ischemic events.     

Bleeding risks with abciximab after full-dose thrombolysis in rescue or urgent angioplasty for acute myocardial infarction

BACKGROUND: The bleeding risk associated with platelet glycoprotein IIb/IIIa inhibition in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) after full-dose thrombolysis for acute myocardial infarction (AMI) is unclear. We examined the risk and predictors of bleeding complications in patients with AMI who received abciximab during rescue or urgent PTCA after full-dose thrombolytic therapy. METHODS: A multicenter retrospective cohort of 147 consecutive patients who underwent PTCA within 48 hours after full-dose thrombolysis for AMI was studied. Bleeding events (major, minor, nuisance) from the onset of AMI to discharge were compared between those who received abciximab (n = 57) and those who did not (n = 90). RESULTS: Baseline clinical characteristics were similar between the two groups. Despite lower doses of procedural heparin, the incidence of non-coronary artery bypass graft-related major and minor bleeding was higher in the abciximab group than in controls (63% vs 39%, P =.004). Although the risk of major bleeding was 4-fold with abciximab (12% vs 3%, P =.04), only one intracranial and one fatal bleeding event occurred. Multivariable regression identified abciximab therapy as the most powerful independent predictor of combined major and minor bleeding, with a hazard risk ratio of 1.9 (P =.04). CONCLUSIONS: In the setting of rescue or urgent PTCA within 48 hours after full-dose thrombolytic therapy after AMI, major and particularly minor bleeding were frequently encountered. The adjunctive use of abciximab increased these bleeding risks by approximately 2-fold.     

Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants

BackgroundDirect oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding.ObjectivesThe aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding.MethodsThe investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model.ResultsThe investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used.ConclusionsThe risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.     

Lower gastrointestinal bleeding--management

Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.     

A review of oral anticoagulants,old and new,in major bleeding and the need for urgent surgery

Oral anticoagulants, old and new, are effective therapies for prevention and treatment of venous thromboembolism and reduction of stroke risk in patients with atrial fibrillation. However, blocking elements of the clotting cascade carries an inherent risk of bleeding. Also, anticoagulated patients sometimes require urgent surgery or invasive procedures. This has led to the emergence of a body of scientific literature on the reversal of anticoagulation in these two settings. Traditionally, vitamin K antagonists (VKAs), which indirectly inactivate clotting factors II, VII, IX and X (and natural anticoagulant proteins C and S), had been the mainstay of oral anticoagulation for half a century. Only a few years ago, the US Food and Drug Administration (FDA) approved a specific VKA reversal agent, 4-Factor Prothrombin Complex Concentrate (4F-PCC). The last decade has seen the rise of non-Vitamin K oral anticoagulants (NOACs), which target specific factors, i.e. Factors IIa and Xa. Investigators have rapidly developed reversal agents for these agents as well, idarucizumab for the Factor IIa inhibitor dabigatran (Pradaxa) and andexanet alfa for the entire class of Factor Xa inhibitors (FXaIs), currently four drugs: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa) and betrixaban (Bevyxxa). Clinicians still use off-label PCC for reversing FXaIs in some settings, and a universal reversal agent, ciraparantag, remains in development. This review summarizes the safety and efficacy of these reversal agents in the setting of anticoagulant-associated major bleeding and the need for urgent surgery.     

Antiplatelet Therapy and Cardiac Surgery: Review of Recent Evidence and Clinical Implications

Since the publication of the 2009 Canadian Cardiovascular Society position paper on antiplatelet therapy and cardiac surgery, new antiplatelet strategies with either double-dose clopidogrel or with new and more potent agents (prasugrel and ticagrelor) have become accepted practice. For the patient requiring coronary artery bypass surgery who has recently received either double-dose clopidogrel or one of the new P2Y12 platelet inhibitors, increased perioperative bleeding can be anticipated. For patients who are stable and can wait, surgery should be delayed for 5 days after the last dose of clopidogrel (standard or double-dose), and for 7 days after the last dose of prasugrel. Patients who have received ticagrelor should wait 5 days after the last dose before surgery, although it is likely that surgery can be safely performed 3 days after discontinuing ticagrelor. For patients who require emergency surgery despite recently receiving double-dose clopidogrel, prasugrel, or ticagrelor, the measures to limit perioperative bleeding discussed in the 2009 Canadian Cardiovascular Society position paper remain applicable, but have not yet been rigourously tested. Recent studies have suggested the value of preoperative in vitro platelet aggregometry to determine perioperative bleeding risk.     

Safety of "bridging" with eptifibatide for patients with coronary stents before cardiac and non-cardiac surgery

Patients with previously implanted coronary stents are at risk for stent thrombosis if dual-antiplatelet therapy is prematurely discontinued. Bridging with a glycoprotein IIb/IIIa inhibitor has been advocated as an alternative, with few supporting data. The aim of this study was to determine the safety of such a strategy by retrospectively analyzing bleeding in 100 consecutive patients with previously implanted coronary stents who were bridged to surgery with eptifibatide after discontinuing thienopyridine therapy. A propensity-matched control comparison was performed for a subgroup of 71 patients who underwent cardiovascular surgery. Blood transfusions were required in 65% in the bridged group versus 66% in the control group (p = 0.86). The mean numbers of units transfused were 4.84 ± 6.93 and 3.65 ± 7.46, respectively (p >0.25). Rates of return to the operating room for bleeding or tamponade were 10% and 2.9%, respectively (p = 0.085). Increased rates of transfusion were noted for patients who received concomitant aspirin and/or intravenous heparin infusion. In conclusion, there does not appear to be any increase in the need for blood transfusions or rate of return to the operating room for patients being bridged with eptifibatide when thienopyridines are discontinued in the perioperative period, but concomitant use of additional antiplatelet or anticoagulant agents may increase transfusions and delays to surgery. Clinicians who are considering this strategy must weigh the risks of stent thrombosis versus bleeding.     

Complications and limitations of injection sclerotherapy in portal hypertension.

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.     

Editorial: Urgent colonoscopy in lower GI bleeding: not so fast

The role of urgent colonoscopy in lower gastrointestinal bleeding (LGIB) remains controversial. Although some studies have shown that examinations performed within 12-24 h of admission improve diagnostic yield and reduce rebleeding and surgery, others have not. In this issue of the American Journal of Gastroenterology, Laine and Shah present a randomized trial of urgent (<12 h from admission) vs. elective (36-60 h from admission) colonoscopy in 72 patients with LGIB. A total of 15% of patients with presumed LGIB were found to have upper gastrointestinal bleeding, highlighting the importance of excluding a gastroduodenal source in patients with severe hematochezia. The majority of patients with LGIB (72%) stopped bleeding spontaneously, and there were no differences in rebleeding, blood transfusions, diagnostic or therapeutic interventions, length of hospital stay, or hospital charges in patients undergoing urgent vs. elective colonoscopy. However, the limited number of patients in this study and the fact that patients in the urgent colonoscopy arm appeared to have more severe bleeding than those undergoing elective examinations make it difficult to draw conclusions regarding the utility of urgent vs. elective colonoscopy in LGIB.     

Intravenous proton pump inhibitors before endoscopy in bleeding peptic ulcer with high-risk stigmata: a multicentre comparative study.

BACKGROUND: It is not clear if starting intravenous proton pump inhibitors (IV PPI) before endoscopic therapy provides additional benefit over starting it afterward in patients with high-risk ulcer stigmata of peptic ulcer disease. METHODS: All patients who received IV pantoprazole bolus and infusion and underwent endoscopy in six Canadian hospitals over 20 months were reviewed. Only patients with high-risk ulcer stigmata (arterial bleeding, oozing, nonbleeding visible vessel or adherent clot) were included. Patients receiving IV PPI before endoscopy (before group) were compared with those who received it after endoscopy (after group) with respect to endoscopic findings and, secondarily, to patient demographics and clinical outcomes. RESULTS: The demographics and baseline characteristics of the before group (n=57) and the after group (n=109) were similar. The before group was more likely to have had IV PPI started outside of daytime hours, and median time to endoscopy in patients admitted with upper gastrointestinal bleeding was 24 h (interquartile range 9.5 to 35) in the before group and 11.3 h (interquartile range 3.7 to 17.2) in the after group (P<0.0001). At the time of endoscopy, 33% of patients in the before group had actively bleeding lesions (Forrest 1a or 1b) compared with 54% in the after group (P=0.01), but there were no significant differences in rebleeding, surgical rates, intensive care unit admission or death between the groups. CONCLUSION: IV PPI infusions before endoscopy may lower the proportion of actively bleeding peptic ulcer lesions at endoscopy, but this finding does not appear to affect rates of rebleeding, surgery or death.     

Thrombocytopenia and bleeding in dental procedures of patients with Gaucher disease

Summary. The risk of bleeding during dental procedures may be increased in patients with Gaucher disease. We aimed to evaluate potential coagulation and platelet function abnormalities and targeted therapy accordingly. Patients with type 1 Gaucher disease who were treated at the Oral and Maxilo‐Facial surgery clinic at Sheba Medical Center between 2003 and 2010 comprised the study cohort. Data collected included disease history, enzyme treatment, platelet counts, dental therapy and outcome. Bleeding was defined as excessive bleeding during or immediately following procedure. Coagulation studies and platelet function tests including aggregometry were performed on all patients. Dental procedures (n = 14, including eight teeth extractions, two crown lengthening procedures, one cyst enucleation and three deep dental scaling) of seven patients were studied. Mean platelet count prior to procedure was 73 K ± 14.8 mm³. Patients bleeding risk score was calculated according to previous history of bleeding tendency, degree of thrombocytopenia, presence of comorbid coagulopathy and the type of dental procedure. Two patients with highest risk score received prophylactic platelet transfusions, three patients (medium‐risk) received DDAVP preprocedure and all received systemic tranexamic acid, which was the only systemic therapy for low‐risk patients. Meticulous surgical local haemostasis was applied. No excessive intra‐operative or postoperative bleeding occurred. Patients with Gaucher disease who have thrombocytopenia and abnormal platelet function tests may be safely treated if meticulous haemostasis is applied along with systemic therapy as required. Platelet transfusions are not mandatory and should be applied considering the procedure‐related risk and the patient’s calculated haematological risk for bleeding.     

Safety of glycoprotein IIb/IIIa inhibitors in urgent or emergency coronary artery bypass graft surgery

Approximately 2% to 4% of patients undergo urgent or emergency coronary artery bypass grafting (CABG) for complications of percutaneous coronary intervention (PCI) after treatment with glycoprotein (GP) IIb/IIIa inhibitors. The pharmacokinetic and pharmacodynamic properties of GP IIb/IIIa inhibitors play a large role in determining the safety of their use in the setting of urgent or emergency CABG procedures. Emergency or urgent CABG after treatment with the GP IIb/IIIa inhibitor, abciximab, may be associated with increased risk of hemorrhage and the requirement of platelet transfusions if surgery is performed within 12 h of abciximab discontinuation. Eptifibatide is associated with a similar risk compared with placebo, even when surgery is performed within 2 h of eptifibatide cessation. Limited data for tirofiban show that bleeding is not increased when compared with acetylsalicylic acid or heparin. Eptifibatide and tirofiban appear to have favourable safety profiles compared with abciximab in the setting of emergency or urgent CABG after failed PCI.     

The effect of preoperative blood transfusion on morbidity and survival in colorectal malignancy.

BACKGROUND/AIMS: It is believed that blood transfusions adversely affect colorectal cancer surgery. However, intra- and postoperative blood transfusions represent urgent interventions, and immeasurable confounding factors may affect the shortand long-term outcome. Therefore, we compared colorectal cancer patients who had received preoperative blood transfusion with patients who did not receive transfusions with regard to postoperative complications and long-term outcome. METHODS: The records of 333 patients who were operated for colorectal malignancy between 1980 and 1995 were evaluated. RESULTS: Sixty-one patients (18.3%) received preoperative blood transfusions. Wound infection rate was higher (14.2% vs 1.9%) in the no-transfusion group. Disease-free survival was not different between the groups (p=0.134). Cumulative survival was adversely affected in the preoperative transfusion group (p=0.012). However, preoperative blood transfusion did not emerge to be an independent factor for wound infection or for death on follow-up when the confounding factors were corrected. CONCLUSION: Preoperative transfusion during surgery for colorectal malignancy does not result in an increase in postoperative complications, long-term failure or death rates.