Does off-hours endoscopic hemostasis affect outcomes of nonvariceal upper gastrointestinal bleeding?

Aim: Different researches showed controversial results about the ‘off-hours effect’ in nonvariceal upper gastrointestinal bleeding (NVUGIB). Materials & methods: A total of 301 patients with NVUGIB were divided into regular-hours group and off-hours group based on when they received endoscopic hemostasis, and the relationship of the clinical outcomes with off-hours endoscopic hemostasis was evaluated. Results: Patients who received off-hours endoscopy were sicker and more likely to experience worse clinical outcomes. Off-hours endoscopic hemostasis was a significant predictor of the composite outcome in higher-risk patients (adjusted OR: 4.63; 95% CI: 1.35–15.90). However, it did not associate with the outcomes in lower-risk patients. Conclusion: Off-hours effect may affect outcomes of higher-risk NVUGIB patients receiving endoscopic hemostasis (GBS ≥12).

Gastrointestinal Bleeding in Congenital Bleeding Disorders

Gastrointestinal bleeding (GIB) is serious, intractable, and potentially life-threatening condition. There is considerable heterogeneity in GIB phenotypes among congenital bleeding disorders (CBDs), making GIB difficult to manage. Although GIB is rarely encountered in CBDs, its severity in some patients makes the need for a comprehensive and precise assessment of underlying factors and management approaches imperative. Initial evaluation of GIB begins with assessment of hematological status; GIB should be ruled out in patients with chronic anemia, and in presentations that include hematemesis, hematochezia, or melena. High-risk patients with recurrent GIB require urgent interventions such as replacement therapy for treatment of coagulation factor deficiency (CFD). However, the best management strategy for CFD-related bleeding remains controversial. While several investigations have identified CBDs as potential risk factors for GIB, research has focused on assessing the risks for individual factor deficiencies and other CBDs. This review highlights recent findings on the prevalence, management strategies, and alternative therapies of GIB related to CFDs, and platelet disorders.

Predictive Role of Admission Venous Lactate Level in Patients with Upper Gastrointestinal Bleeding: A Prospective Observational Study

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies. Risk stratification is essential in patients with this potentially life-threatening condition. The aim of this prospective study was to evaluate the usefulness of the admission venous lactate level in predicting clinical outcomes in patients with UGIB. All consecutive adult patients hospitalized due to UGIB were included in the study. The clinical data included the demographic characteristics of the observed population, etiology of UGIB, need for surgical intervention and intensive care, bleeding recurrence, and mortality rates. Venous lactate was measured in all patients on admission. Logistic regression analyses were used to calculate the odds ratios (OR) of lactate levels for all outcomes. The receiver operating characteristic (ROC) curve was used to determine the accuracy of lactate levels in measuring clinical outcomes, while Youden index was used to calculate the best cut-off points. A total of 221 patients were included in the study (151M; 70F). There were 24 cases of UGIB recurrence (10.8%), 19 patients (8.6%) required surgery, and 37 individuals (16.7%) required intensive care. Mortality rate was 11.3% (25 cases). The logistic regression analysis showed statistically significant association between admission venous lactate and all clinical outcomes: mortality (OR = 1.39, 95%CI: 1.22–1.58, p < 0.001), recurrence of bleeding (OR = 1.16, 95%CI: 1.06; 1.28, p = 0.002), surgical intervention (OR = 1.17, 95%CI: 1.06–1.3, p = 0.002) and intensive care (OR = 1.33, 95%CI: 1.19–1.5, p < 0.001). The ROC curve analysis showed a high predictive value of lactate levels for all outcomes, especially mortality: cut-off point 4.3 (AUC = 0.82, 95%CI: 0.72–0.92, p < 0.001) and intensive care: cut-off point 4.2 (AUC = 0.76, 95%CI: 0.66–0.85, p < 0.001). Admission venous lactate level may be a useful predictive factor of clinical outcomes in patients with UGIB.

Gastrointestinal Bleeding During Direct Oral Anticoagulants Therapy in Patients With Nonvalvular Atrial Fibrillation and Risk of Polypharmacy

Although concomitant medications have been raised as a factor affecting hemorrhage during direct oral anticoagulants (DOACs) therapy, details remain unelucidated. This study was conducted to clarify the relationship between concomitant medications with possible pharmacokinetic interactions and number of concomitant medications, and bleeding and embolism in patients with nonvalvular atrial fibrillation on DOACs. The subjects were 1,010 patients prescribed DOACs between April 2011 and June 2018. The study investigated their course between the first prescription and December 2018, including the presence or absence of clinically relevant bleeding, gastrointestinal bleeding (GIB), and major cardiovascular and cerebrovascular events (MACCE). Impacts of medications were evaluated by the general linear model with inverse probability-weighted propensity score. The observation period was 2,272 patient-years. The rate of bleeding was 4.7%/year, GIB was 2.8%/year, and MACCE was 2.0%/year. Taking 10 or more oral medications concurrently was a significant risk for GIB (hazard ratio, 2.046 [1.188–3.526]; p = 0.010). Nonsteroidal anti-inflammatory drugs (NSAIDs) was the only significant risk for GIB. Clinicians should be aware of gastrointestinal bleeding when using DOACs with patients taking more than 10 medications and/or NSAIDs.

Video Capsule Endoscopy Optimal Timing in Overt Obscure Gastrointestinal Bleeding

Video capsule endoscopy (VCE) has become the noninvasive diagnostic standard in the investigation of overt obscure gastrointestinal bleeding (OGIB), with a high positive and negative predictive value. However, the diagnostic yield of the VCE is thought to depend on when it was performed. We evaluate the optimal timing performing VCE relative to overt OGIB to improve the diagnostic yield. A total 271 patients had admitted and underwent VCE for overt OGIB between 2007 and 2016 in Samsung Medical Center, Seoul, Korea. To evaluate the diagnostic yield of VCE for overt OGIB with respect to timing of the intervention, diagnostic yield was analyzed according to the times after latest bleeding. The finding of VCE was classified into P0 or P1 (no potential for bleeding or uncertain hemorrhagic potential) and P2 (high potential for bleeding, such as active bleeding, typical angiodysplasia, large ulcerations or tumors). The P2 lesion was found in 106 patients and diagnostic yield of was 39.1% for overt OGIB. Diagnostic yield of VCE to detect P2 lesion was higher when it is performed closer to the time of latest bleeding (timing of VCE between the VCE and latest bleeding: <24 h, 43/63 (68.3%); 1 days, 16/43 (34.9%); 2 days, 18/52 (34.6%); 3 days, 13/43 (30.2%); 4 days, 7/28 (25.0%); 5–7 days, 6/24 (25.0%), and ≥8 days, 4/18 (22.2%); ptrend <0.001). The interval between the VCE and latest bleeding were categorized into <24 h (n = 63), 1–2 days (n = 95), 3–7 days (n = 95) and ≥8 days (n = 18). Multivariable analyses showed the odds ratio for P2 lesion detection was 4.99 (95% confidence interval, 1.47–16.89) in <24 h group, compared with ≥8 days group (p < 0.010). The overall re-bleeding rate for those with P2 lesion was higher than for those with P0 or P1 lesion at the end of mean follow up of 2.5 years. The proportion of patients who underwent therapeutic intervention including surgery, endoscopic intervention and embolization was higher when VCE is performed closer to the time of latest bleeding (p = 0.010). Early deployment of VCE within 24 h of the latest GI bleeding results in a higher diagnostic yield for patients with overt OGIB and consequently resulted in a higher therapeutic intervention rate.