Top PDF A STUDY ON ENDOSCOPIC EVALUATION OF UPPER GASTROINTESTINAL BLEEDING

The mean age of patients was 47.03 years with male: female ratio of 2.33:1. 58% of patients were first time bleeders. Majority of patients presented with melaena. Visualisation of active bleeding achieved to 85.7% when endoscopy was done within first 24 hrs. The commonest cause of UGIB was duodenal ulcer (DU) which accounted for 41% cases. Gastric ulcer was responsible in 13% of cases. Portal hypertension was responsible for bleed in only 13%. Neoplasms accounted for 25% of cases. Other less common causes were erosive gastritis (3%), gastric polyp (3%), Mallory-Weiss tear (1%), and Dieulafoy’s lesion (1%). Among bleeding peptic ulcers, 27.8% of cases were classified as Forrest IIa and 20.4% in Forrest IIb & IIc each. Acid peptic disease was past history elicited in majority (33%) followed by NSAID (26%) and alcohol (26%).

With regard to the evaluated outcomes, it was found that exposure to antithrombotics had no significant impact on 30-day mortality nor on the need for endoscopic retreat- ment or urgent surgery. Regarding the 30-day relapse rate, it was found that the exposed group appeared to be pro- tected, since a higher percentage of non-exposed patients (11.4% vs 6.4%) showed a new episode of NVUGB after effective hemostasis with a statistically significant differ- ence. These findings are in agreement with T. Solakoglu et al., who have put forth the use of longer duration PPI infusion in the exposed group as a possible explanation. It was recognized that an appropriate duration of this therapy was essential to allow for the healing of the gastrointesti- nal mucosa and to prevent recurrence in high-risk patients (15). Another possible explanation could be the greater prophylactic use of PPIs in the exposed group (21.5% vs 20.3%); however, a lack of statistical significance makes this a less likely hypothesis.

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We inves- tigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan’s National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new- onset CAD patients with AMI (AMI [+] ) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI [−] ) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB [−] patients, UGIB [+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72–2.50). In the subgroup analysis for gender and age, UGIB [+] women (AOR = 2.70; 95% CI, 2.03–3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56–3.18) had higher odds of an AMI. UGIB [+] AMI [+] patients used nonsignificantly less aspirin than did UGIB [−] AMI [+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.

endoscopes are part of the team. In UK, just 37% (76/205) of the facilities had a nurse (trained in the use of therapeutic endoscopic techniques) on call endoscopy rota. A survey of the practice of after-hours and emergency endoscopy in Canada concluded that more than one-third of surveyed endoscopists across the country didn't have a trained endoscopy nurse to assist in after-hours endoscopy and that significant regional differences in the practice of after-hours endoscopy were observed (Muthiah, Enns et al. 2012). This is a quite disturbing finding as the need for appropriate technical assistance is more common during emergency procedures when haemostatic interventions are performed at a much higher rate than during the regularly scheduled procedures. But quality of care must be measured with continued and increased vigor. And clinical audit is a professionally way to participate in performance evaluation and a way to show accountability for quality of care. But clinical audit needs to be effective, by describing the exact improvement, select a strategy, design the change needed and operate the new way. This was not the case in UK. The two earlier surveys of the provision of out-of-hours endoscopy services in the UK (i.e., an on call rota of endoscopists) has not increased from the 50% reported by 150 hospitals in 2002 and the 49% reported in 2005(Douglass, Bramble et al. 2005; Gyawali, Suri et al. 2007). And in 2012, Jairath and al. published the results of a prospective audit that analyzed the outcomes of NVAUGIB in relation to time to endoscopy (Jairath, Kahan et al. 2012). Only 48% of endoscopies were performed within 24h and only 61% of the patients, classified with high risk stigmata of bleeding received therapeutic intervention. The emergency referral system was addressed in an Italian paper that concluded that in Lazio region, 30-day mortality rate from NVAUGIB, is lower when patients are admitted to EDs with greater resources (Cesaro, Kohn et al. 2013). The authors suggested the need for a better organization of the emergency referral system because high risk were less frequently referred to better levels of care. In our cohort, this does not seem to be a problem since, 15% of the patients had a clinical Rockall risk score ≥ 4 and after endoscopy, 60% were high risk patients.

In 2006 and 2008, we asked participants to report any episodes of gastrointestinal bleeding which required hospitalization or blood transfusion, a definition consistent with previous studies [12]. Participants were also asked to provide the anatomic location of the bleed (esophagus, stomach, duodenum, colon/rectum, other, unknown) and the year of the bleed (in categories) over the entire cohort study period. We classified cases into upper and lower gastrointestinal bleeding; upper bleeding was defined as bleeding originating from the esophagus, stomach, and duode- num; lower bleeding was defined as bleeding arising from the colon or rectum. As a validation, we verified accuracy of self- reports by reviewing medical records among a subsample of 239 men who reported bleeding in which we archived blood specimens in 1993–95 for a separate study of genetic risk factors for bleeding. The baseline characteristics of the cohort of men who provided a blood specimen were generally similar to men who did not. Two study physicians (gastroenterologists) blinded to exposure infor- mation, reviewed and extracted the data based from hospital records, discharge summaries, endoscopy reports and pathology reports if biopsy specimens were taken. We found the correlation between self-reported date of diagnosis and confirmed date of diagnosis was 0.87 (P-value ,0.001). The accuracy of the self- reported classification of upper and lower gastrointestinal bleeding was 93.3% (95% confidence interval [CI], 88.8%–96.4%). The etiology of bleeding was validated based on the reports from endoscopy, bleeding scans or angiograms when available. For

ABSTRACT – Context - Portal vein thrombosis refers to a total or partial obstruction of the blood low in this vein due to a thrombus formation. It is an important cause of portal hypertension in the pediatric age group with high morbidity rates due to its main complication - the upper gastrointestinal bleeding. Objective - To describe a group of patients with portal vein thrombosis without associated hepatic disease of the Pediatric Hepatology Clinic of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil with emphasis on diagnosis, presentation form and clinical complications, and the treatment of portal hypertension. Methods - This is a descriptive study of a series of children and adolescents cases assisted from January 1990 to December 2010. The portal vein thrombosis diagnosis was established by ultrasound. Results - Of the 55 studied patients, 30 (54.5%) were male. In 29 patients (52.7%), none of the risk factors for portal vein thrombosis was observed. The predominant form of presentation was the upper gastrointestinal bleeding (52.7%). In 20 patients (36.4%), the initial manifestation was splenomegaly. During the whole following period of the study, 39 patients (70.9%) showed at least one episode of upper gastrointestinal bleeding. The mean age of patients in the irst episode was 4.6 ± 3.4 years old. The endoscopic procedure carried out in the urgency or electively for search of esophageal varices showed its presence in 84.9% of the evaluated patients. The prophylactic endoscopic treatment was performed with endoscopic band ligation of varices in 31.3% of patients. Only one died due to refractory bleeding. Conclusions - The portal vein thrombosis is one of the most important causes of upper gastrointestinal bleeding in children. In all non febrile children with splenomegaly and/or hematemesis and without hepatomegaly and with normal hepatic function tests, it should be suspect of portal vein thrombosis. Thus, an appropriate diagnostic and treatment approach is desirable in an attempt to reduce morbidity and mortality.

post hemostasis PPI regimen of 80 mg intravenous bolus followed by 8 mg/hour continuous infusion [191]. In that meta-analysis, Sachar et al reported that the risk ratio of recurrent ulcer bleed- ing within 7 days for intermittent infusion of PPI vs. bolus plus continuous infusion of PPI was 0.72 (upper boundary of one-si- ded 95 %CI 0.97), with an absolute risk difference of −2.64%. Risk ratios for other outcomes, including radiologic/surgical interven- tion and mortality, showed no differences between infusion regi- mens. These meta-analytic data indicate that intermittent PPI therapy appears comparable to the currently recommended regi- men of intravenous bolus plus continuous PPI infusion post endoscopic hemostasis. It should be noted however, that inter- mittent PPI bolus dosing is associated with a somewhat higher risk of rebleeding that in general can be managed endoscopically. Given the pharmacodynamic profile of PPIs, consideration should be given to use of high dose PPI infusion given at least twice-dai- ly, and using high dose oral PPIs in patients able to tolerate oral medications [191]. The concept of high dose PPI varies between the different studies used in the meta-analysis conducted by Sa- char et al. However, it appears that an 80 mg oral PPI dose fol- lowed by 40 –80mg orally every 12 hours for 72 hours yields an intragastric pH similar to that reported with continuous intrave- nous PPI infusion following successful endoscopic hemostasis of high risk peptic ulcers [192]. This is but one study, and therefore we need more data to confirm these findings before drawing firm practical conclusions for the post-endoscopy management of pa- tients with NVUGIH. These data are in agreement with an RCT that randomized patients to high dose continuous infusion of esomeprazole vs. 40 mg of oral esomeprazole twice-daily for 72 hours (118 vs. 126 patients respectively) [193]. Recurrent bleed- ing at 30 days was reported in 7.7 % and 6.4 % of patients, respec- tively (difference −1.3 percentage points, 95%CI −7.7 to 5.1 per- centage points). However, this study was conducted in an Asian population (e. g., PPI slow metabolizers) and its findings may not be generalizable to Western NVUGIH populations. Moreover, this study was stopped prematurely since it was not designed as an equivalency trial, and based on the preliminary data, thousands of patients would have been required in order to complete the study. (See Appendix e8, online-only.)

When our study protocol was first prepared, four studies had been published [2–5]; three of those studies found odds ratios of 3 or more and only one, clearly heterogeneous in design, found no risk [3]; thus, our study had power to detect an odds ratio of 2 and failed to detect an association between SSRI exposure and occurrence of upper GI bleeding of this magnitude; in it, we have found a clear association with NSAIDs in the range of that reported in the literature [21]. When considering the different groupings of antidepressants there were no differences. This is consistent with the results of another case-control study similarly conducted with the same protocol and in a close similar healthcare setting [10]. Out of 15 studies conducted so far (Table 3), 4 found a strong significant association (a relative risk value higher than 2) [2,5,7,11], 5 found a significant mild association (a risk value between 1 and 1.7) [9,12,13,15,16] and 5 did not find any association at all [3,8,10,14, present study]; in the remaining two studies, the outcome variables were not entirely comparable to those of the other studies, but a trend to an increased risk was observed with increased serotonin inhibition reuptake [4,6]. Since all these studies have been conducted during different periods, in different geographical areas and healthcare settings, with different designs and different ways of collecting information, the explanation of those different estimates may lie on this heterogeneity; nevertheless, retrospective or prospective character seems to be a remarkable factor of heterogeneity (Table 3); thus, only 1 out of 4 prospective studies published so far found a significant risk while, in the retrospective studies, it was 9 in 12 which found a significant risk. It is possible that, since most of these retrospective studies have been conducted with pre-existing information –not collected for the purposes of these particular studies– some relevant confounding factors might be

ABSTRACT - Background - Bleeding ulcers are a major problem in public health and represent approximately half of all the cases of upper gastrointestinal hemorrhage in the United States. This study aims to determine the prognostic value of factors such as clinical history, laboratory and endoscopic findings in the occurrence of new episodes of bleeding in patients who have upper gastrointestinal hemorrhage caused by gastric or duodenal peptic ulcer. Methods - A cohort study with 94 patients was designed to investigate prognostic factors to the occurrence of new episodes of bleeding. Results - From the 94 patients studied, 88 did not present a new bleeding episode in the 7 days following hospital admission. The incidence of rebleeding was significantly higher in those patients with hemoglobin <6 g/dL at the admission (P = 0.03, RR = 6.2). The localization of the ulcers in bulb was positively associated to rebleeding (P = 0.003).The rebleeding group needed a greater number of units transfunded (P = 0.03) and the time of hospitalization was longer than the time of the hemostasia group (P = 0.0349). Conclusions - The identification of patients with risk of death by bleeding peptic ulcer remains as a challenge, once few factors are capable of predicting the severity of the evolution. The identification of such factors will allow the choice of the better therapeutic conduct improving the diagnosis and decreasing the rate of rebleeding and the mortality.

patients had previous digestive bleeding and presented mild to moderate mononuclear inlammatory iniltration, hyper- emia and capillary ectasia in histopathological evaluation. We showed a decrease of PHC intensity by endoscopy and histopathological assessment. However, due to the small number of patients in this study, the differences were not statistically signiicant. In this series, the histomorphome- try demonstrated a signiicant reduction in the vessel areas, diameters and thickness in the mucous membranes of the rectum, sigmoid colon and ascending colon. We observed a greater reduction in vessel diameter than in the thickness and area. This positive response is due to the inluence of portal pressure reduction in vessel diameter. On the other hand, the vessel thickness depends on tissue collagen deposition, which is a more persistent alteration and it takes more time to decrease. Currently, the endoscopic treatment for portal hypertension gastrointestinal bleeding due to esophageal varices is endoscopic band ligation (1, 17) . However, it was

Introduction: The incidence of gastrointes- tinal disorders among patients with chron- ic kidney disease (CKD) is high, despite the lack of a good correlation between endoscopic findings and symptoms. Many services thus perform upper gastrointesti- nal (UGI) endoscopy on kidney transplant candidates. Objectives: This study aims to describe the alterations seen on the upper endoscopies of 96 kidney-transplant candi- dates seen from 2014 to 2015. Methods: Ninety-six CKD patients underwent up- per endoscopic examination as part of the preparation to receive kidney grafts. The data collected from the patients’ medical records were charted on Microsoft Office Excel 2016 and presented descriptively. Mean values, medians, interquartile ranges and 95% confidence intervals of the clinic and epidemiological variables were calcu- lated. Possible associations between endo- scopic findings and infection by H. pylori were studied. Results: Males accounted for 54.17% of the 96 patients included in the study. Median age and time on dialy- sis were 50 years and 50 months, respec- tively. The most frequent upper endoscopy finding was enanthematous pangastritis (57.30%), followed by erosive esophagi- tis (30.20%). Gastric intestinal metaplasia and peptic ulcer were found in 8.33% and 7.30% of the patients, respectively. H. py- lori tests were positive in 49 patients, and H. pylori infection was correlated only with non-erosive esophagitis (p = 0.046). Conclusion: Abnormal upper endoscopy findings were detected in all studied pa- tients. This study suggested that upper endoscopy is a valid procedure for kidney transplant candidates. However, prospec- tive studies are needed to shed more light on this matter.

ABSTRACT - Context - Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs. Objective - The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding. Methods - From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, irst liquid intake, soft/solid diet prescription, irst soft/solid intake. Results - From 133 patients (84 men) Rockall classiication was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the irst day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy. Conclusions - Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.

persisted for more than 24 hours with associated leukocytosis. Spontaneous bacterial peritonitis was based on classical criteria. Eighty-nine patients were evaluated. Fourty-six patients presented with UGB, and 43 patients had no UGB (control). There were infections recorded in 25/46 (54%) patients with UGB, and 15/43 (35%) in those without UGB (p=0.065). The ratio of the number of infections/admitted patients, was significantly larger in the group with UGB (0.78 ± 0.89 vs. 0.39 ± 0.62; p=0.028) since patients had more than one infection. In the UGB group compared to non UGB group, ascites was more frequent (67% vs. 42%; p=0.027); they were more likely to have undergone endoscopic procedures (p<0.001) and the mean ± SD for platelets count was smaller (96,114 ± 57,563 vs. 145,674 ± 104,083; p=0.007). The results show that UGB is an important contribution to bacterial infection among Child B and C cirrhotic patients.

8. Perlman R, Callum J, Laflamme C, Tien H, Nascimento B, Beckett A, et al. A recommended early goal-directed mana- gement guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients. Critical care. 2016;20(1):107.

We recognize that this study has some limitations. A larger patient group without dysphagia perhaps could have revealed some statistical differences that were not demon- strated in this analysis. Additionally, the inclusion of a group of primary snorers and a control group neither snored snor- ers nor had OSA patients would help to clarify the roles of OSA and snoring in the dysphagia these patients exhibited, perhaps demonstrating differences in pharyngeal swallow- ing pressures between the groups. The use of a validated questionnaire would be more appropriate, but the study was based on a simpler questionnaire used in a similar study since these patients did not have many complaints of dysphagia. Another limitation was the fact that solid-state esophageal manometry which is superior when assessing rapid high-pressure events that occur in the pharynx was not available. 15,33 However, the perfusion method was per-

The presented results from a series of analyses indicate lack of dependence of certain sensitivity analysis parameters. In case of increasing the parameter r (the number the matrix B* is generated) obtaining identical results despite increasing r, may be explained as converging of the results to a certain fixed value. It should be noticed that increase of the number r causes increase of the number of required computer simulations. Therefore it is significant to obtain credible results for the smallest r number possible.

We evaluated the financial impact of inappropriate PPI pres- criptions. Total costs relating solely to inappropriate PPI use as- cended to €1079.96 in the three month period. Mean price per patient per hospital stay was €2.12. These costs are based on pricing per pill of oral esomeprazole or IV pantoprazole ampoule alone. Consumables such as catheters and syringes were not accounted for as well as human resources and possible iatroge- nic effects of PPI administration. Thus, there are potential savings to be made with PPI as far as the inpatient setting is concerned. A better description of costs involved can be seen on Table 4.

O melanoma maligno é a causa mais comum de lesão metastática no trato gastrointestinal (GI), representando cerca de 33% de todos os tumores malignos metastáticos do tubo digestivo 1.. As[r]

Hypoxia developing during upper gas- trointestinal endoscopy is a well-recognized complication; however, its cause has not been well clarified. Sedation might prima- rily cause hypoxia by inducing respiratory depression, while the presence of an endo- scope may also cause hypoxia by narrowing the upper airway (19). In a study conducted on 330 patients, Banks et al. (20) demon- strated that the arterial oxygen pressure was considerably decreased in patients with se- dation compared to those without, while Wang et al. (19) observed hypoxia in both patients with and without sedation, but stressed that sedation significantly increased hypoxia. Yazawa et al. (18) found a reduc- tion in arterial oxygen pressure in the group with sedation compared to that without, but the reduction was not statistically signifi- cant. In another study, Kýlýc et al. (21) reported that sedation with midazolam does not have unfavorable effects on arterial oxy- gen saturation, but might show unfavorable effects in patients who smoke or patients who have pulmonary problems. In the pres- ent study, the patients in both groups were healthy individuals with ASA scores of 1 or 2. Unlike Kýlýc et al. (21), we found signifi- cant reductions in SpO 2 levels in the sedated

Crimean-Congo Haemorrhagic Fever (CCHF) dis- ease is a viral haemorrhagic fever syndrome pres- ent in Turkey since 2002 [1]. CCHF is transmitted by ticks and can be fatal. Thrombocytopenia and coagulopathy can develop and, because of severe bleeding in the gastrointestinal tract, the prognosis is poor. After 3-7 days of incubation, fever, head- ache, fatigue, generalised muscle pain, nausea, vomiting, and skin and mucosal haemorrhages can occur [2]. J Microbiol Infect Dis 2016;6(1): 38-39 Key words: CCHF, endoscopy, gastrointestinal bleeding