Search Results (28)

Rare presentations are surprising and may disturb the day-to-day routine of a medical unit; however, they are expected (not as individual entities, but as a group of “uncommon causes”). While reviewing the literature in relation to three clinical cases of upper gastrointestinal bleeding (UGIB) encountered in our institution—gastric metastases of breast cancer (GMB), pyloric gland adenoma, and gastrointestinal stromal tumor (GIST)—we identified seven and 29 case reports for the first two entities, and over 100 publications addressing GIST. This prompted a shift in focus from novel reporting to diagnostic contextualization. We found it difficult to obtain an overview of the spectrum of UGIB etiologies, as most publications refer to a few individual entities or to a subgroup of rare causes. The narrative review we conducted arose from this particular research methodology. Based on a broad literature search, UGIB etiologies were organized in five categories (lesions of the mucosa, neoplasms, vascular causes, bleeding predisposition, and external sources of bleeding). In the management of patients with UGIB, the underlying etiology deviates from the classic peptic ulcer disease/esophageal varices dyad in approximately half of the cases. This underscores the need for heightened clinical vigilance, particularly in complex scenarios, where endoscopic findings, imaging results, and histopathological interpretations may be unexpected or prone to misinterpretation. As an illustration, we conducted two systematic reviews of case reports of bleeding GMB and PGA. Our findings support a proactive diagnostic and research mindset and advocate for improved awareness of uncommon UGIB etiologies. Full article

Background: Upper Gastrointestinal Bleed (UGIB) is a common and potentially life-threatening condition with an annual incidence of 80–150 per 100,000 individuals and a mortality rate of 2–10%. Esophagogastroduodenoscopy (EGD) is the gold standard for both diagnosis and treatment, but post-discharge outcomes, including readmissions, remain underexplored. Methods: This study utilized the 2021 National Readmission Database (NRD) to analyze 30-day readmission rates following EGD for UGIB. Adult patients (≥18 years) admitted for UGIB and undergoing EGD were included; those who died during the index hospitalization were excluded. Demographic, clinical, and socioeconomic factors associated with readmission were examined using multivariate logistic regression. Results: Among 34,257 patients admitted for UGIB and undergoing EGD, 11,088 (32.4%) were readmitted within 30 days, with 5423 (49%) due to recurrent UGIB. Readmitted patients had a higher mean age (68.46 vs. 67.63 years) and greater prevalence of cirrhosis (16.71% vs. 13.84%). Hospital resource utilization was significantly higher among readmissions, with increased total hospital charges (USD 82,544.82 vs. USD 61,521.17) and longer hospital stays (5.38 vs. 4.97 days). Mortality was lower among readmitted patients (1.46% vs. 3.53%). Multivariate analysis identified cirrhosis (OR 7.20, 95% CI: 6.45–8.02), untreated H. pylori infection (OR 3.43, 95% CI: 2.15–4.30), atrial fibrillation (OR 1.52, 95% CI: 1.36–1.69), and chronic antithrombotic therapy (OR 1.63, 95% CI: 1.41–1.89) as significant predictors of recurrent UGIB readmission. Lower socioeconomic status was also associated with increased readmission risk (OR 1.15, 95% CI: 1.05–1.25). Conclusions: Readmission following EGD for UGIB is common and driven primarily by recurrent bleeding. Cirrhosis, untreated H. pylori infection, atrial fibrillation, and chronic anticoagulation therapy are key risk factors. These findings highlight the need for targeted interventions, including improved post-discharge management and optimization of anticoagulation strategies, to reduce readmission rates and improve patient outcomes. Full article

Background/Objectives: To evaluate the efficacy and safety of using tantalum-loaded Obsidio conformable embolic (Ta-OCE) in gastroduodenal artery (GDA) embolization for upper gastrointestinal bleeding (UGIB), employing a novel “open-sandwich” technique. Methods: An institutional review board (IRB)-approved retrospective analysis was conducted on patients who underwent GDA embolization for UGIB using Ta-OCE between May 2023 and June 2024, using an “open-sandwich” technique. Briefly, the retrograde sources of flow, namely the right gastroepiploic artery (RGEA), was commonly embolized with a single, usually detachable, coil at its proximal aspect. Beginning within the proximal RGEA adjacent to the coil and distal to the site of extravasation and/or an endoscopically placed clip, Ta-OCE was then instilled in a continuous fashion to the origin of GDA. Technical success was defined as complete occlusion of the target vessel without immediate procedural complications. Clinical success was assessed as the absence of rebleeding within 4 weeks post-embolization. Adverse events were evaluated using Common Toxicity Criteria for Adverse Events (v.5). Results: Overall, a total of 10 patients, with a mean age of 67.3 years, underwent Ta-OCE embolization for UGIB. A technical success rate of 100% was achieved with no instances of immediate procedural complications. Clinical success was achieved in eight patients (80%). Re-intervention was required in two patients in whom the proximal GDA and distal GDA/proximal RGEA were not embolized adequately, respectively. A significant change in mean hemoglobin levels was observed 24 h pre- and post-embolization, with a mean increase of 1.47 g/dL. Conclusions: Despite the small sample size, lack of control group, and retrospective design, the “open-sandwich” technique combining Ta-OCE with a single coil appears to be an effective and safe method of GDA embolization in the setting of UGIB. Larger multicenter studies are needed to further evaluate the feasibility of this technique. Full article

Background: For over a decade, endoscopic hemostatic powders have been used to manage upper gastrointestinal bleeding (UGIB). Various preclinical benchtop and animal models have been developed to evaluate these devices. Multiple companies have released hemostatic powders to market, assessing their safety and efficacy using an established porcine gastric vessel bleed model. The model requires inserting an artery segment into the gastric lumen, which is then punctured to produce a bleed. This simulates an aggressive arterial bleed, allowing hemostatic prototype devices to be tested under challenging conditions. Methods: We aimed to evaluate the relationship between intragastric pressure and bleed severity by injecting the gas used to deliver hemostatic powder to the bleed site without administering the hemostatic powder. Results: Our results indicate that elevated intragastric pressures alone can cause bleed cessation. Additional findings suggest that other factors in the model can lead to false positive hemostasis. Conclusions: This study highlights limitations in the current state porcine gastric vessel bleed model. The results underscore the importance of vetting preclinical models before acquiring efficacy data and the need to develop more robust and effective bleed models for testing hemostatic devices. Full article

Objectives: Posttraumatic upper gastrointestinal bleeding (UGIB) is a very rare consequence of blunt liver trauma. It can be quite a diagnostic challenge for clinicians, as it can clinically manifest many weeks after the trauma or be scantily symptomatic. Methods: The following article would like to provide an analysis of clinical cases of 13 patients following blunt liver injuries, the main symptoms of which was bleeding into the gastrointestinal tract through the biliary tree. The article is research of the published literature concentrating on the influence of modern diagnostic methods (scintigraphy, USG and CT) on the diagnosis and long-term survival of patients with haemobilia caused by blunt liver trauma. In each patient, the condition was presented with UGIB symptoms following blunt trauma, before initiation of operative treatment or before death. The cases were divided into 2 groups: prior to and after introduction of modern diagnostic procedures, and then compared together. Results: The study indicates that liver damage can cause symptoms of UGIB, even after minor abdominal trauma and with delayed and uncharacteristic symptoms. Conclusions: Modern diagnostic methods, such as ultrasound, scintigraphy and CT, make it easier to identify these injuries and choose appropriate treatment, reducing the risk of death. Full article

Introduction: Upper gastrointestinal bleeding (UGIB) is among the most common causes of morbidity and mortality worldwide, accounting for major resource allocation and increasing incidence. This study aimed to evaluate the severity of non-variceal bleeding in patients at risk of bleeding through the use of NSAIDs, oral anticoagulants, and antiplatelet therapy. Material and Method: The study included 296 patients admitted in the Gastroenterology Department of the Municipal County Emergency University Hospital, Timisoara, between 01.01.2018 and 01.04.2020, and diagnosed via gastroscopy with non-variceal gastrointestinal bleeding. The patients were divided among four groups based on their use of different drugs known to induce UGIB, i.e., aspirin and clopidogrel, NOACs, NSAIDs, and anti-vitamin K drugs, respectively. Statistical analyses were performed based on ANOVA one-way tests for continuous variables and Chi-square tests for categorical variables with pairwise comparisons based on Bonferroni adjusted significance tests. Results: The results showed several parameters having statistical significance among the different groups of patients. Patients on NOACs had statistically significant lower hemoglobin levels, lower hematocrit values, lower erythrocytes, lower RDW and higher fibrinogen levels compared to patients on VKA. Discussion: Surprisingly, the results from our study suggest that the use of NOACs was associated with a higher risk of bleeding when compared to VKA, which differs from the existing literature. Conclusions: One of the important factors causing upper non-variceal bleeding can be iatrogenic, either due to antiplatelet drugs or anticoagulants, to which NSAID treatment is additionally associated for various reasons. In our study, the use of NOACs seemed to have a more severe bleeding spectrum with higher morbidity compared to VKA. Full article

Upper gastrointestinal bleeding (UGIB) is a significant concern in children, contributing to 6–20% of cases in pediatric intensive care units. This study evaluates the roles of Helicobacter pylori (H. pylori) infection and non-steroidal anti-inflammatory drug (NSAID) usage in the etiology of UGIB in children, with a particular focus on trends observed during the COVID-19 pandemic. We conducted a retrospective analysis of 103 pediatric patients who underwent esophagogastroduodenoscopy (EGD) for UGIB between January 2015 and December 2023. Of these, 88 patients were included in the final analysis, where the source of bleeding was successfully identified. Hematemesis was the most common presentation, and the source of bleeding was identified in 85.43% of cases. The prevalence of H. pylori infection remained stable across the pre-pandemic (39.7%) and post-pandemic (36.7%) periods. However, NSAID usage increased nearly threefold during the pandemic, with 36.7% of post-pandemic UGIB cases associated with NSAID use, compared to 12.1% pre-pandemic. These findings underscore the significant roles of H. pylori and NSAID use in pediatric UGIB, with a notable increase in NSAID-related cases during the pandemic. Full article

Background: Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide’s efficacy compared to erythromycin. Methods: We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. Results: Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. Conclusions: The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide. Full article

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan’s National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors. Full article

Background: Several risk scores have attempted to risk stratify patients with acute upper gastrointestinal bleeding (UGIB) who are at a lower risk of requiring hospital-based interventions or negative outcomes including death. This systematic review and meta-analysis aimed to compare predictive abilities of pre-endoscopic scores in prognosticating the absence of adverse events in patients with UGIB. Methods: We searched MEDLINE, EMBASE, Central, and ISI Web of knowledge from inception to February 2023. All fully published studies assessing a pre-endoscopic score in patients with UGIB were included. The primary outcome was a composite score for the need of a hospital-based intervention (endoscopic therapy, surgery, angiography, or blood transfusion). Secondary outcomes included: mortality, rebleeding, or the individual endpoints of the composite outcome. Both proportional and comparative analyses were performed. Results: Thirty-eight studies were included from 2153 citations, (n = 36,215 patients). Few patients with a low Glasgow-Blatchford score (GBS) cutoff (0, ≤1 and ≤2) required hospital-based interventions (0.02 (0.01, 0.05), 0.04 (0.02, 0.09) and 0.03 (0.02, 0.07), respectively). The proportions of patients with clinical Rockall (CRS = 0) and ABC (≤3) scores requiring hospital-based intervention were 0.19 (0.15, 0.24) and 0.69 (0.62, 0.75), respectively. GBS (cutoffs 0, ≤1 and ≤2), CRS (cutoffs 0, ≤1 and ≤2), AIMS65 (cutoffs 0 and ≤1) and ABC (cutoffs ≤1 and ≤3) scores all were associated with few patients (0.01–0.04) dying. The proportion of patients suffering other secondary outcomes varied between scoring systems but, in general, was lowest for the GBS. GBS (using cutoffs 0, ≤1 and ≤2) showed excellent discriminative ability in predicting the need for hospital-based interventions (OR 0.02, (0.00, 0.16), 0.00 (0.00, 0.02) and 0.01 (0.00, 0.01), respectively). A CRS cutoff of 0 was less discriminative. For the other secondary outcomes, discriminative abilities varied between scores but, in general, the GBS (using cutoffs up to 2) was clinically useful for most outcomes. Conclusions: A GBS cut-off of one or less prognosticated low-risk patients the best. Expanding the GBS cut-off to 2 maintains prognostic accuracy while allowing more patients to be managed safely as outpatients. The evidence is limited by the number, homogeneity, quality, and generalizability of available data and subjectivity of deciding on clinical impact. Additional, comparative and, ideally, interventional studies are needed. Full article

Background: High-dose proton pump inhibitor (PPI) therapy, given either intermittently or continuously for non-variceal upper gastrointestinal bleeding (NV-UGIB), is efficacious. Using intermittent PPI for low-risk patients may be cost-saving. Our objective was to estimate the annual cost savings if all low-risk NV-UGIB patients received intermittent PPI therapy. Methods: Patients who presented to hospital in Calgary, Alberta, who received a PPI for NV-UGIB from July 2015 to March 2017 were identified using ICD-10 codes. Patients were stratified into no endoscopy, high-risk, and low-risk lesion groups and further subdivided into no PPI, oral PPI, intermittent intravenous (IV), and continuous IV subgroups. Average length of stay (LOS) in each subgroup and costs were calculated. Results: We identified 4141 patients with NV-UGIBs, (median age 61, 57.4% male). One-thousand two-hundred and thirty-one low-risk patients received continuous IV PPI, with an average LOS of 6.8 days (95% CI 6.2–7.3) versus 4.9 days (95% CI 3.9–5.9) for intermittent IV patients. If continuous IV PPI patients instead received intermittent IV PPI, 3852 patient days and CAD 11,714,390 (2017 CAD)/year could be saved. Conclusions: Using real-world administrative data, we demonstrate that a sizable portion of low-risk patients with NV-UGIB who were given continuous IV PPI if switched to intermittent IV therapy could generate significant potential cost savings. Full article

Upper gastrointestinal bleeding is a common medical emergency. Thorough initial assessment and appropriate resuscitation are essential to stabilise the patient. Risk scores provide an important tool to discriminate between lower- and higher-risk patients. Very low-risk patients can be safely discharged for out-patient management, while higher-risk patients can receive appropriate in-patient care. The Glasgow Blatchford Score, with a score of 0–1, performs best in the identification of very low-risk patients who will not require hospital based intervention or die, and is recommended by most guidelines to facilitate safe out-patient management. The performance of risk scores in the identification of specific adverse events to define high-risk patients is less accurate, with no individual score performing consistently well. Ongoing developments in the use of machine learning models and artificial intelligence in predicting poor outcomes in UGIB appear promising and will likely form the basis of dynamic risk assessment in the future. Full article

Introduction: The execution of upper endoscopy at the proper time is key to correctly managing patients with upper gastrointestinal bleeding (UGIB). Nonetheless, the definition of “time” for endoscopic examinations in UGIB patients is imprecise. The primary aim of this study was to verify whether the different definitions of “time” (i.e., the symptoms-to-endoscopy and presentation-to-endoscopy timeframes) impact mortality. The secondary purpose of this study was to evaluate the similarity between the two timeframes. Methods: A post-hoc analysis was performed on a prospective multicenter cohort study, which included UGIB patients admitted to 50 Italian hospitals. We collected the timings from symptoms and presentation to endoscopy, together with other demographic, organizational and clinical data and outcomes. Results: Out of the 3324 patients in the cohort, complete time data were available for 3166 patients. A significant difference of 9.2 h (p < 0.001) was found between the symptoms-to-endoscopy vs. presentation-to-endoscopy timeframes. The symptoms-to-endoscopy timeframe demonstrated (1) a different death risk profile and (2) a statistically significant improvement in the prediction of mortality risk compared to the presentation-to-endoscopy timeframe (p < 0.0002). The similarity between the two different timeframes was moderate (K = 0.42 ± 0.01; p < 0.001). Conclusions: The symptoms-to-endoscopy and presentation-to-endoscopy timeframes referred to different timings during the management of upper endoscopy in bleeding patients, with the former being more accurate in correctly identifying the mortality risk of these patients. We suggest that further studies be conducted to validate our observations, and, if confirmed, a different definition of time should be adopted in endoscopy. Full article

Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures. Methods: We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019. Results: Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic. Conclusions: COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment. Full article

(1) Background: The assessment of mortality and rebleeding rate in upper gastrointestinal bleeding (UGIB) is essential, and several prognostic scores have been proposed. Some patients with UGIB did not undergo endoscopy, either because they refused the procedure, suffered from alcohol withdrawal symptoms or altered general status, or because the bleeding was severe enough to cause death before the endoscopy. The mortality risk in the subgroup of patients without endoscopy is poorly evaluated in the literature. (2) Methods: The purpose of the study was to identify the most useful scores for the assessment of in-hospital mortality in patients with UGIB with no endoscopy performed and no known etiology. A total of 198 patients with UGIB and no endoscopy performed were admitted between January 2017 and December 2021 and the accuracy of 12 prognostic scores and the Charlson comorbidity index for in-hospital mortality prediction were analyzed, as well as Child–Pugh Turcotte (CPT) and Meld scores in patients with cirrhosis. (3) Results: The mortality rate was 37.9%, higher than in variceal (21.9%, p < 0.0001) and non-variceal bleeding (7.4%, p < 0.0001). The most accurate scores by AUC were the International Bleeding score (INBS, 0.844), Glasgow Blatchford (0.783), MAP score (0.78), Iino (0.766), AIM65 and modified N-score (0.745 each), modified Glasgow-Blatchford (0.73), H3B2 and N-score (0.701); Rockall, Baylor, and T-score had an AUC below 0.7. MELD score was superior to CPT in patients with cirrhosis (AUC 0.811 versus 0.670). (4) Conclusions: The mortality rate in UGIB with no endoscopy was higher than in both variceal and non-variceal bleeding and was higher in the pandemic period but with no statistical significance (45.3% versus 32.14%, p = 0.0586), mainly because of positive cases. Only one case of rebleeding was noted; the hospitalization period was significantly shorter. The most accurate score was International Bleeding Score; the MELD score had a higher but moderate accuracy compared with CPT in patients with cirrhosis. Full article