The Utility of Upper Endoscopy in Patients with Concomitant Upper Gastrointestinal Bleeding and Acute Myocardial Infarction

Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996–December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%–4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.     

Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial

BACKGROUND & AIMS: Upper gastrointestinal bleeding (UGIB) is a severe and frequent complication of cirrhosis. Recombinant coagulation factor VIIa (rFVIIa) has been shown to correct the prolonged prothrombin time in patients with cirrhosis and UGIB. This trial aimed to determine efficacy and safety of rFVIIa in cirrhotic patients with variceal and nonvariceal UGIB. METHODS: A total of 245 cirrhotic patients (Child-Pugh < 13; Child-Pugh A = 20%, B = 52%, C = 28%) with UGIB (variceal = 66%, nonvariceal = 29%, bleeding source unknown = 5%) were randomized equally to receive 8 doses of 100 microg/kg rFVIIa or placebo in addition to pharmacologic and endoscopic treatment. The primary end point was a composite including: (1) failure to control UGIB within 24 hours after first dose, or (2) failure to prevent rebleeding between 24 hours and day 5, or (3) death within 5 days. RESULTS: Baseline characteristics were similar between rFVIIa and placebo groups. rFVIIa showed no advantage over standard treatment in the whole trial population. Exploratory analyses, however, showed that rFVIIa significantly decreased the number of failures on the composite end point (P = 0.03) and the 24-hour bleeding control end point (P = 0.01) in the subgroup of Child-Pugh B and C variceal bleeders. There were no significant differences between rFVIIa and placebo groups in mortality (5- or 42-day) or incidence of adverse events including thromboembolic events. CONCLUSIONS: Although no overall effect of rFVIIa was observed, exploratory analyses in Child-Pugh B and C cirrhotic patients indicated that administration of rFVIIa significantly decreased the proportion of patients who failed to control variceal bleeding. Dosing with rFVIIa appeared safe. Further studies are needed to verify these findings.     

Remitting seronegative symmetrical synovitis pitting oedema after BCG instillation

Remitting seronegative symmetrical synovitis pitting oedema (RS3PE) is a distinct form of seronegative rheumatoid arthritis like polyarthritis. It is characterized by late onset symmetrical joint involvement and pitting oedema of hands and feet (JAMA 254(19):2763–2767, [1]). Polyarthritis secondary to intravesical Bacillus Calmette Guerin (BCG) therapy has been reported (Clin Rheumatol 21:536–537, [2]). To our knowledge, about 0.5% of patients receiving BCG instillation presented polyarthritis, but only one case of RS3PE has been reported (J Rheumatol 28:1699–1701, [3]). We described the second case of RS3PE following intravesical BCG instillation of bladder carcinoma.     

Treatment of therapy-resistant sarcoidosis with adalimumab

A possible role of tumor necrosis factor alpha (TNFα) in the pathomechanism of sarcoidosis must be considered in the analysis of this disorder since elevated concentrations of this cytokine have been found. In addition, TNFα expression could be demonstrated in sarcoid granulomata [1]. It is well known that TNFα plays a crucial role in granulomatous inflammation, e.g., in mycobacterial diseases [2]. Therefore, TNFα blockade is a potential approach in the therapy for sarcoidosis. Up to now, various cases of therapy-resistant sarcoidosis treated with anti-TNFα (infliximab and etanercept) have been reported [3–8]. Here, we describe successful treatment using adalimumab, a human recombinant immunoglobulin (Ig) G1 anti-TNF monoclonal antibody [9].     

Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia

Background and aimsGastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients.MethodsWe performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates.ResultsThe final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05).ConclusionOur data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.     

Novel Nasogastric Tube-Related Criteria for Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Bleeding

Background

Patients with active upper gastrointestinal bleeding (UGIB) require urgent endoscopy, but appropriate criteria for urgent endoscopy in these patients have not yet been established.

Aims

The goal of this study is to establish a simple system for the selection of UGIB patients who may benefit from urgent endoscopy.

Methods

Of the 335 patients who required emergency hospitalization for UGIB from May 2010 to March 2012 at Nagoya Daini Red Cross Hospital, 166 patients who underwent placement of a nasogastric tube (NGT) were retrospectively identified. Active bleeding on the endoscopic image was used as an endpoint that reflected the need for urgent endoscopy.

Results

The ratio of the heart rate to the systolic blood pressure (HR/SBP ratio) and aspiration of fresh or dark red fluid from the NGT [NGT(+)] were significant predictors of active bleeding in the univariate analysis [HR/SBP ratio, P = 0.016; NGT(+), P < 0.001]. The HR/SBP ratio [odds ratio (OR) 8.118; 95 % confidence intervals (CI) 1.696–38.850; P = 0.009] and NGT(+) (OR 4.630; 95 % CI 2.092–10.204; P < 0.001) were also significantly associated with active bleeding in the multivariate analysis. Moreover, receiver operating characteristic analysis revealed a setting with HR/SBP ratio >1.4 or NGT(+) to be optimal criteria to predict active bleeding. These criteria were associated with a sensitivity of 64.9 % (24/37) and a specificity of 76.7 % (99/129) for the prediction of active bleeding; consequently, they are superior to the sensitivity and specificity of previously proposed criteria.

Conclusions

A novel and simple criteria system using NGT(+) and HR/SBP is a good predictor of the need for urgent endoscopy in patients with nonvariceal UGIB.     

Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta

Background and Study Aims

Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta.

Methods

Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6 %) patients who were proved to have cirrhosis were the subject of the present study.

Results

From all cirrhotic portal hypertensive patients, 415 (75.5 %) bled from variceal sources (esophageal and gastric) while 135 (24.5 %) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding.

Conclusions

Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.

     

Upper gastrointestinal bleeding in the setting of excessive warfarin anticoagulation: Risk factors,and clinical outcome

AimGastrointestinal tract is the most common source of severe bleeding following excessive warfarin anticoagulation (EWA). We aimed to describe the risk factors and outcome associated with upper gastrointestinal bleeding (UGIB) in patients admitted with EWA.MethodsDemographics, clinical, laboratory and endoscopic findings of patients admitted with EWA from 2003 to 2015 were reviewed. Hospital mortality, blood product utilization and hospital length of stay were recorded. Regression analyses were performed for prediction of GI bleeding and mortality in patients with EWA.ResultsMedical records of 157 women and 121 men were reviewed. From 41 patients presented with UGIB, 31 (75.6%) underwent esophagogastroduodenoscopy. Preexisting peptic ulceration (32.2%) was the most common source of bleeding in these patients. Hospital mortality was 9.8% in patients with UGIB which was similar to those without. In average, patients with UGIB required 2 units more packed red blood cells and fresh frozen plasma. Older age (P = 0.045) and previous history of peptic ulcer disease (P < 0.001) were the predictors of UGIB in patients with EWA.ConclusionPresence of past or current peptic disorders was the strongest predictor of UGIB in patients with EWA. Despite comparable hospital mortality, these patients required more transfusion of blood products.     

Portal Venous Flow Pattern as a Useful Tool for Predicting Esophageal Varix Bleeding in Cirrhotic Patients

This study aimed to evaluate whether (1) the portal venous flow pattern determined by color Doppler sonography could be related to the clinical severity of liver cirrhosis and (2) whether the flow patterns differ between patients with bleeding and nonbleeding esophageal varices. One hundred twenty-nine cirrhotic patients and 60 noncirrhotic healthy controls were enrolled after endoscopic survey for the presence of esophageal varices. Each patient received color Doppler echography to define the pattern of blood flow direction as hepatopetal or nonhepatopetal (hepatofugal, turbulence, and bidirection) in type. The patients with esophageal varices were further categorized into two groups: with recent bleeding (BEV; n = 99) and without recent bleeding (NBEV; n = 30). More patients in the BEV group (72.7%) had a nonhepatopetal Doppler flow pattern than in the control group (1.7%) and NBEV group (13.3%) (P < 0.001). Among the 129 cirrhotic patients, the nonhepatopetal flow pattern of the portal vein was higher in 96% of Child–Pugh grade C patients than in 41.8% of grade A patients and 57.6% of grade B patients (P < 0.05). Moreover, for those cirrhotic patients with Child–Pugh grades A and B, the nonhepatopetal Doppler flow pattern was more commonly found in the BEV group than in the NBEV group (63.0 vs. 13.8%; odds ratio, 10.64; 95% CI, 0.03–0.299; P < 0.001). Portal venous blood flow pattern is related to severity of cirrhosis. The presence of a nonhepatopetal flow pattern implicates an increased risk of esophageal varices bleeding, especially for those cirrhotic patients with Child–Pugh grades A and B.     

Upper GI Bleeding in an Emergency Hospital: Etiology,Prognosis and Improved Survival by Endoscopic Hemostasis

Acute upper gastrointestinal bleeding (UGIB) is a frequent diagnosis prompting hospital admission or complicating another preexisting condition. This report examines the experience of an urban medical center in the utilization of endoscopy and endoscopic hemostasis in the diagnosis and management of UGIB over a four-year period. The first portion of this study examines 562 admissions to a single institution with UGIB. The most common causes of bleeding were acute gastric mucosal lesions (AGML), 24%; esophageal varices (EV), 22%; gastric ulcers, 19%; duodenal ulcers, 14%; Mallory-Weiss tears, 11%; and esophagitis, 3%. Nonoperative treatment was sufficient in the majority of patients (89.5%). Endoscopic therapy was utilized in 144 patients (26%), of whom 12 required a subsequent operation. Fifty-eight patients (10.5%) underwent surgery; however, emergent operations were required in only 2.5% of the patients. Factors correlating with mortality included shock at the time of admission (SBP < 80), transfusion requirements of > 5 U PRBC, and presence of EV (each p < 0.001). The second part of this study examines the effect of thrombogenic sclerotherapy on both short and long-term survival in 101 patients referred with bleeding esophageal varices. Alcoholic cirrhosis was responsible for the majority (88%) of EV, and most patient were Child's C classification (84%). In long-term follow-up, rebleeding was significantly reduced (p = 0.03) in patients compliant with follow-up sclerotherapy. A trend toward decreased mortality was noted in patients compliant with sclerotherapy and in those who avoided further alcohol usage.     

Acute nonvariceal upper gastrointestinal hemorrhage

Opinion statement  

Risk factors for mortality among patients admitted with upper gastrointestinal bleeding at a tertiary hospital: a prospective cohort study

Background

Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency, which is potentially fatal. Proper management of UGIB requires risk-stratification of patients which can guide the type and aggressiveness of management. The aim of this was study was identify the causes of UGIB and factors that increase the risk of mortality in these patients.

Methods

This was a prospective cohort study conducted over a period of seven months at a tertiary hospital. Adults admitted with UGIB were included in the study. Demographic data, laboratory parameters and endoscopic findings were recorded. Patients were then followed up for 60 days to identify the occurrence of mortality. Chi-square tests and cox-regression was used to determine association between risk factors and mortality in the bivariate and multivariate analysis, respectively.

Results

A total of 170 patients with UGIB were included. Males accounted for the majority (71.2%). Median age of the study population was 40.0 years. Chronic liver disease was present in 30.6% of study patients. The most common cause of UGIB among the 86 patients who underwent endoscopy was oesophageal varices (57%), followed by peptic ulcer disease (18%) and gastritis (10%). Mortality occurred in 57 patients (33.5%) and was significantly higher in patients with high white blood cell count (HR 2.45, p 0.011), raised serum alanine aminotransferase (HR 4.22, p 0.016), raised serum total bilirubin (HR 5.79, p 0.008) and lack of an endoscopic procedure done (HR 4.40, p <0.001). Rebleeding was reported in 12 patients (7.1%) and readmission due to UGIB in 4 patients (2.4%)

Conclusions

Oesophageal varices was the most common cause of UGIB. One-third of patients admitted with upper gastrointestinal bleeding died within 60 days of admission, signifying a high burden. Rebleeding and readmission rates were low. A high WBC count, raised serum ALT, raised serum total bilirubin and a lack of endoscopy were independent predictors of mortality. These findings can be used to risk-stratify patients who may benefit from early and more aggressive management.

     

Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study

GOALS: To assess epidemiologic features and predictive factors of mortality of acute upper gastrointestinal bleeding (UGIB). STUDY: During a 6-month period, a prospective population-based study including all the UGIB occurring in a geographic area of 3 million people was conducted. Data from cirrhotic patients were compared with those of noncirrhotic patients. RESULTS: A total of 2,133 UGIB were recorded, 21.9% in cirrhotic patients (n = 468). Endoscopic hemostasis was performed in 46.5% and 8.3% in cirrhotic and noncirrhotic patients, respectively (P < 0.001). Mortality during hospitalization was 23.5% in cirrhotic patients and 11.2% in noncirrhotic patients (P < 0.001). Six independent predictive factors of mortality were observed in both patient groups: a prothrombin level less than 40%, an UGIB occurring in inpatients, a concomitant digestive carcinoma, a hematemesis revealing the UGIB, a recent use of steroid drugs, and age over 60 years. Four other predictive factors of mortality were also identified in noncirrhotic patients. CONCLUSIONS: Although epidemiologic features, clinical course, management, and prognosis of UGIB were quite different in cirrhotic and noncirrhotic patients, the majority of predictive factors of mortality were the same in both patient groups. These data underline the major role of debilitated status and hepatic failure in the prognosis of UGIB in cirrhotic patients.     

Review of Stem Cell-Based Therapy for the Treatment of Cardiovascular Disease

Cardiovascular disease remains the number one cause of mortality in the United States. Nearly 2,400 Americans die of cardiovascular disease each day, an average of 1 every 37 s [1]. One in three Americans has been diagnosed with one or more forms of cardiovascular disease. Most recent estimates show that, in the United States alone, 16 million people have coronary artery disease and 5.3 million have been diagnosed with heart failure. Unlike other forms of cardiovascular disease, heart failure is often the end-stage of a cardiovascular disease, frequently coronary artery disease. The 1-year mortality of people diagnosed with heart failure remains a sobering 20%. Heart failure is also very costly. The estimated direct and indirect cost of heart failure in the US for 2008 is 34.8 billion dollars [1]. Therefore, advanced treatment options for these populations could greatly impact patient health outcomes and cost savings. Even with the advancements in pharmacologic therapies and improvements in mechanical support devices, the only definitive treatment for advanced heart failure remains heart transplantation. Given the limited availability of donor organs for use in orthotopic heart transplantation, alternative therapies including stem cell-based therapies have been explored. The past decade has seen an explosion of activity of the field of cardiac regeneration. New scientific techniques and discoveries have allowed rapid advancements but there have also been conflicting opinions and results. The concept of cardiac regeneration is now commonly accepted but the exact mechanisms and extent of regeneration is greatly debated. Several candidate cell populations, both cardiac and extracardiac, have been reported to be capable of cardiac regeneration [2–10]. However, some studies question if these cell populations actually differentiate into cardiomyocytes but rather function through paracrine effects or through cell fusion [11–13, 14–19]. Despite these challenges, the field has also begun translating the preclinical animal studies into human clinical trials using several cell types for the treatment of many clinical disease states. This review will highlight the preclinical animal studies and review the results of the published clinical trials.     

Spontaneous pneumomediastinum secondary to refractory dermatomyositis successfully treated with rituximab

Spontaneous pneumomediastinum has been described in patients with dermatomyositis (DM) and polymyositis (Korkmaz et al., Rheumatology 40:476–478, 2001; Maruoka et al., Mod Rheumatol 16:55–57, 2006; Kono et al., Ann Rheum Dis 59:372–376, 2000; Neves et al., Clin Rheumatol 26:105–107, 2007). Literature reviews suggest that this complication has a mortality of between 27% and 41% ( Kono et al., Ann Rheum Dis 59:372–376, 2000; Neves et al., Clin Rheumatol 26:105–107, 2007; Goff et al., Arthritis Rheum 61:108–118, 2009). This is the first report of rituximab being used successfully as part of the treatment for DM complicated by pneumomediastinum.     

内镜静脉曲张结扎术与十四肽生长抑素治疗肝硬化食管静脉曲张破裂出血的疗效比较

目的 比较内镜静脉曲张结扎术与十四肽生长抑素在治疗肝硬化食管静脉曲张破裂出血中的效果.方法 将2003年1月至2006年4月广东省江门市中心医院消化科收治的80例肝硬化食管静脉曲张破裂出血患者分为内镜治疗组(40例)和十四肽生长抑素治疗组(40例).内镜治疗组在内镜下用多环连发皮圈结扎器行静脉曲张结扎术(EVL),然后静脉滴注垂体后叶素7 d;生长抑素治疗组先以十四肽生长抑素持续静脉滴注72 h,再以垂体后叶素静脉滴注持续4 d.结果 内镜治疗组中39例72 h内止血(97.5%).1个月内再出血4例(10%,其中1周内再出血3例),发生肝肾综合征1例,肝性脑病1例,死亡2例(5%).生长抑素治疗组72 h完全止血32例,1个月内再出血5例(12.5%),出现肝肾综合征5例(12.5%),P＞0.05;肝性脑病6例(15%),P＜0.05;死亡6例(15%),P＞0.05.结论 食管静脉曲张皮圈结扎治疗肝硬化食管静脉曲张破裂大出血优于生长抑素治疗,尽早EVL治疗能减少肝性脑病的发生.     

经内镜栓塞术联合套扎术治疗食管胃底静脉曲张出血的疗效观察

目的探讨胃底静脉曲张栓塞术联合内镜下食管静脉曲张套扎术（EVL）治疗肝硬化上消化道出血的疗效。方法经急诊胃镜检查发现活动性胃底静脉曲张出血合并Ⅱ°以上食管静脉曲张且排除其他病因的上消化道出血患者共156例,分为治疗组和对照组,治疗组胃底静脉曲张组织粘合剂栓塞同时食管静脉EVL治疗;对照组胃底静脉曲张组织粘合剂栓塞治疗2个月后行食管静脉EVL。结果两组均未发生与治疗相关的并发症。止血成功率治疗组为96．3％（77／80）,对照组为97．4％（74／76）,（P〉0．05）;近期再出血率治疗组为6．4％（5／78）,对照组为21．3％（16／75）,两组差异有统计学意义（P〈0．05）;两组患者随访6个月,再出血率分别为13．0％（9／69）、25．4％（17／67）,差异有统计学性意义（P〈0．05）。胃底静脉曲张改善总有效率治疗组和对照组分别为61．6％、59．1％,食管曲张静脉改善总有效率为74．0％、67．9％,差异均无统计学意义。结论胃底静脉曲张栓塞联合EVL是治疗肝硬化胃底静脉曲张出血并食管静脉曲张的安全有效方法,同时联合治疗更能降低再出血率。     

Giant Heterotopic Pancreas Presenting with Massive Upper Gastrointestinal Bleeding

Heterotopic pancreas, or pancreatic rest, refers to extra-pancreatic tissue without an obvious vascular or anatomic connection with the pancreas. Although the frequency of heterotopic pancreatic tissue in autopsy series has been reported as high as 14%, clinical manifestations are rare [2]. Although common in the upper gastrointestinal tract, heterotopic pancreatic tissue rarely causes gastrointestinal bleeding. In a large case series following patients with heterotopic pancreatic tissue, only 7 of 212 patients had any evidence of bleeding [3]. We present a patient who presented with massive hematochezia found to have a giant heterotopic pancreas in the duodenum.     

Helicobacter pylori and Bleeding Duodenal Ulcer: Prevalence of the Infection and Role of Non-steroidal Anti-inflammatory Drugs

Background: Several authors have reported low prevalence of Helicobacter pylori infection in patients with upper gastrointestinal bleeding (UGIB). Our aim was to study the prevalence of H. pylori in bleeding duodenal ulcer (DU), with both invasive and non-invasive methods, and to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs). Methods: Ninety-two patients with bleeding DU were prospectively studied. The use of NSAIDs was evaluated by specific questionnaire. As a control group, 428 patients undergoing outpatient evaluation for the investigation of dyspepsia and found to have a DU at endoscopy were included. At endoscopy, two antral biopsies were obtained (H&E stain). A 13C-urea breath test was carried out in all patients. Breath test was repeated in patients treated with omeprazole during the hospitalization if H. pylori was not detected with the first test. Results: Gastric biopsies could be obtained in 39 patients with UGIB. Three patients with UGIB treated with omeprazole and being H. pylori negative with the first breath test were finally considered infected with the second test. Overall, 92.4% (95% CI, 85%-96%) of the patients with UGIB were infected (89.7% with histology and 92.4% with breath test (P = 0.15)). Concordance kappa value for both diagnostic tests was 0.64. NSAID intake was more frequent in patients with UGIB (34%) than in those without UGIB (5.6%) (P &lt; 0.001), while H. pylori infection was less frequent in patients with UGIB (92.4% (85%-96%)) than in those without UGIB (99.1% (98%-100%); P &lt; 0.001). Even in patients with UGIB, NSAID intake was the only risk factor in 5% of cases. The proportion of cases without H. pylori infection and without NSAID intake was very low in both bleeding and non-bleeding ulcers (2% and 0.5%, respectively; P = 0.146). H. pylori prevalence in bleeding ulcers was of 84% (67%-93%) in patients with NSAID intake, and 96.7% (89%-99%) when patients taking NSAIDs were excluded. In the multivariate analysis, NSAID intake (odds ratio, 9.8 (5.2-18.4)) correlated with UGIB; however, neither H. pylori status nor the interaction between H. pylori infection and NSAID intake correlated with UGIB. In the multivariate analysis in the subgroup of patients with UGIB, NSAID use was the only variable which correlated with H. pylori prevalence (odds ratio, 0.18 (0.03-0.97)). Conclusions: The most important factor associated with H. pylori-negative bleeding DU is NSAID use, and if this factor is excluded prevalence of infection is almost 100% (97%), similar to that found in patients with non-bleeding DU (and without NSAID intake). Bleeding DU patients with neither H. pylori infection nor NSAID use are extremely rare (only 2%), which suggests that the pathogenesis of bleeding DU is similar to that of non-complicated DU disease.     

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding

BACKGROUND:

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source.

OBJECTIVE:

To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation.

METHODS:

A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding.

RESULTS:

The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]).

CONCLUSION:

Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.