Predictors of Early Rebleeding after Endoscopic Therapy in Patients with Nonvariceal Upper Gastrointestinal Bleeding Secondary to High-Risk Lesions

BACKGROUND: In an era of increasingly shortened admissions, data regarding predictors of early rebleeding among patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) exhibiting high-risk stigmata (HRS) having undergone endoscopic hemostasis are lacking.OBJECTIVES: To determine predictors of early rebleeding, defined as rebleeding before completion of recommended 72 h intravenous proton pump inhibitor infusion postendoscopic hemostasis.METHODS: Data from a national registry of patients with upper gastrointestinal bleeding (the REASON registry) were accessed. Univariable and multivariable analyses were sequentially performed to identify significant independent predictors among a comprehensive list of clinical and laboratory characteristics.RESULTS: Overall, 393 patients underwent endoscopic hemostasis for NVUGIB with HRS. Forty patients rebled ≤72 h thereafter (32.5% female, mean [± SD] age 70.2±11.8 years, 2.88±2.11 comorbidities), while 21 rebled later (38.1% female, mean 70.5±14.1 years of age, 2.62±2.06 comorbidities). Hematemesis or bright red blood per nasogastric tube aspirate was identified as the sole independent significant predictor of early rebleeding versus later among both NVUGIB and, more specifically, patients with peptic ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P<0.01, and OR 8.41 [95% CI 1.54 to 46.10]; P=0.014, respectively).CONCLUSIONS: When attempting to determine the optimal duration of pharmacotherapy and timing of discharge for patients following endoscopic hemostasis for NVUGIB with HRS, it is noteworthy that individuals who present with hematemesis or bright red blood per nasogastric tube aspirate are at particularly high risk for rebleeding within the first 72 h.

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Management of acute upper gastrointestinal bleeding

BMJ ◽

10.1136/bmj.l536 ◽

2019 ◽

pp. l536 ◽

Cited By ~ 22

Author(s):

Adrian J Stanley ◽

Loren Laine

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Variceal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Endoscopic Therapy ◽

Ulcer Bleeding ◽

Vasoactive Drugs ◽

Upper Gastrointestinal

Abstract Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.

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Consensus on Control of Risky Nonvariceal Upper Gastrointestinal Bleeding in Taiwan with National Health Insurance

BioMed Research International ◽

10.1155/2014/563707 ◽

2014 ◽

Vol 2014 ◽

pp. 1-8 ◽

Cited By ~ 5

Author(s):

Bor-Shyang Sheu ◽

Chun-Ying Wu ◽

Ming-Shiang Wu ◽

Cheng-Tang Chiu ◽

Chun-Che Lin ◽

...

Keyword(s):

Health Insurance ◽

High Risk ◽

Gastrointestinal Bleeding ◽

National Health Insurance ◽

National Health ◽

Upper Gastrointestinal Bleeding ◽

Ulcer Bleeding ◽

Chronic Obstructive ◽

Research Database ◽

Upper Gastrointestinal

Background and Aims. To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group.Methods. The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade.Results. The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke.Conclusions. The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

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Effectiveness of TC-325 (Hemospray) for treatment of diffuse or refractory upper gastrointestinal bleeding – a single center experience

Endoscopy International Open ◽

10.1055/s-0043-118794 ◽

2017 ◽

Vol 05 (11) ◽

pp. E1159-E1164 ◽

Cited By ~ 11

Author(s):

Oscar Cahyadi ◽

Markus Bauder ◽

Benjamin Meier ◽

Karel Caca ◽

Arthur Schmidt

Keyword(s):

Gastrointestinal Bleeding ◽

Salvage Therapy ◽

Upper Gastrointestinal Bleeding ◽

Clinical Success ◽

Treatment Algorithm ◽

Endoscopic Hemostasis ◽

Ulcer Bleeding ◽

Recurrent Bleeding ◽

Technical Success ◽

Upper Gastrointestinal

Abstract Background and study aims TC-325 (Hemospray, Cook Medical) is a powder agent for endoscopic hemostasis in patients with upper gastrointestinal bleeding (UGIB). Although most publications are based on case-reports and retrospective studies, data on efficacy are promising. Here we report our experience with TC-325 for diffuse or refractory UGIB. Patients and methods Data on patients receiving TC-325 for endoscopic hemostasis from November 2013 to February 2017 at our center were analyzed retrospectively. Primary endpoints were technical success (successful immediate hemostasis) and clinical success (effective hemostasis and no recurrent bleeding). Secondary endpoints were recurrent bleeding within 3 and 7 days, hospital mortality and TC-325 associated complications. TC-325 was used for bleeding not amenable to standard endoscopic treatment (e. g. diffuse bleeding) or as salvage therapy after failure of conventional methods Results Fifty-two patients received TC-325 treatment. Most of the patients were treated for peptic ulcer bleeding (18/52 patients, 34.6 %) and post-interventional bleeding (13/52 patients, 25 %). Hemospray was used in 23/52 (44.2 %) patients as monotherapy and in 29/52 (55.8 %) patients as a salvage therapy. Application of the powder on the bleeding source was successful in all patients with no therapy-related adverse events (AEs). Immediate hemostasis was achieved in 51/52 (98.1 %) patients. Recurrent bleeding within 3 and 7 days was observed in 22/51 and 25/51 patients respectively (43.1 % and 49 %). The overall clinical success was 56.9 % on day 3 and 51 % on day 7. Total mortality was 15.4 % (8 patients), bleeding associated mortality was 3.8 % (2 patients). There were no therapy-related AEs. Conclusions TC-325 showed a high technical success rate as monotherapy for bleeding sources not amenable to standard methods or as an “add-on” therapy after unsuccessful hemostasis. However, rebleeding was frequent in this cohort and further studies are warranted to exactly define a treatment algorithm for TC-325 use.

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The management of the patient with non-variceal upper gastrointestinal bleeding: from evidence to clinical practice

Italian Journal of Medicine ◽

10.4081/itjm.2016.713 ◽

2016 ◽

Vol 11 ◽

Author(s):

Maddalena Zippi ◽

Mariella Frualdo ◽

Luciano Mucci ◽

Marta Zanon ◽

Chiara Marzano ◽

...

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Endoscopic Hemostasis ◽

High Dose ◽

Cardiovascular Risks ◽

High Risk Patients ◽

Epinephrine Injection ◽

Risk Patients ◽

Upper Gastrointestinal

A multidisciplinary group of 7 experts developed this update and expansion of the recommendations on the management of acute non-variceal upper gastrointestinal bleeding (NVUGIH) from guidelines published from 2013. The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews. Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermo-coagulation, alone or with epinephrine injection, are effective methods. Second-look endoscopy may be useful in selected high-risk patients, but is not routinely recommended. Intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIH who require a nonsteroidal anti-inflammatory drug, a PPI is preferred to reduce the rebleeding. Patients with NVUGIH needing secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days).

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