Upper gastrointestinal bleeding in COVID-19 inpatients: Incidence and management in a multicenter experience from Northern Italy.
ABSTRACT: BACKGROUND:COVID-19 patients have an increased susceptibility to develop thrombotic complications, thus thromboprophylaxis is warranted which may increase risk of upper gastrointestinal bleeding (UGIB). Our aim was to evaluate incidence of UGIB and use of upper GI endoscopy in COVID-19 inpatients. METHODS:The medical and endoscopic management of UGIB in non-ICU COVID-19 patients has been retrospectively evaluated. Glasgow Blatchford score was calculated at onset of signs of GI bleeding. Timing between onset of signs of GI bleeding and execution, if performed, of upper GI endoscopy was evaluated. Endoscopic characteristics and outcome of patients were evaluated overall or according to the execution or not of an upper GI endoscopy before and after 24h. RESULTS:Out of 4871 COVID-19 positive patients, 23 presented signs of UGIB and were included in the study (incidence 0.47%). The majority (78%) were on anticoagulant therapy or thromboprophylaxis. In 11 patients (48%) upper GI endoscopy was performed within 24h, whereas it was not performed in 5. Peptic ulcer was the most common finding (8/18). Mortality rate was 21.7% for worsening of COVID-19 infection. Mortality and rebleeding were not different between patients having upper GI endoscopy before or after 24h/not performed. Glasgow Blatchford score was similar between the two groups (13;12-16 vs 12;9-15). CONCLUSION:Upper GI bleeding complicated hospital stay in almost 0.5% of COVID-19 patients and peptic ulcer disease is the most common finding. Conservative management could be an option in patients that are at high risk of respiratory complications.
Project description:Upper gastrointestinal bleeding (UGIB) which occurs proximal to the Treitz ligament is one of the most common cases is emergency medical conditions. The aim of this data article is to evaluation of Rockall and Blatchford scoring systems for predicting the clinical outcomes of patients with upper gastrointestinal bleeding in Imam-Khomeini Hospital, Ahvaz, Iran. This dataset was collected by retrospective descriptive epidemiologic survey which 350 non-cirrhotic patients with UGIB who referred to Ahwaz Imam-Khomeini Hospital for six months. According to the obtained data, in both clinical Rockall and complete Rockall systems, the need for re-endoscopy and the risk of re-bleeding in patients with high scores was more compared to patients with low scores. While, the obtained data about Blatchford score for re-endoscopy and re-bleeding risk was showed which no significant difference. Based on to present dataset, the Rockall systems was superior to Blatchford systems in predicting the re-bleeding as well as the need for re-endoscopy while, none of the systems were efficient in terms of predicting the need for urgent endoscopy and surgery.
Project description:<h4>Background</h4>Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination.<h4>Methods</h4>From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow-Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement.<h4>Results</h4>Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8?%), coffee-ground in 227 patients (46.6?%), and clear in 193 patients (39.6?%). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS???11, whereas no additive value was found when the GBS was greater than 11.<h4>Conclusions</h4>Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.
Project description:The risk of upper gastrointestinal bleeding (UGIB) increases in patients with coronary artery disease (CAD) due to the frequent use of antiplatelets. There is some data reporting on treatment outcomes in CAD patients presenting with UGIB. We aim to determine the clinical characteristics and outcomes of UGIB in patients with CAD, compared with non-CAD patients.We conducted a prospective multi-center cohort study (THAI UGIB-2010) that enrolled 981 consecutive hospitalized patients with acute UGIB. A matched case-control analysis using this database, which was collected from 11 tertiary referral hospitals in Thailand between January 2010 and September 2011, was performed.Of 981 hospitalized patients with UGIB, there were 61 CAD patients and 244 gender-matched non-CAD patients (ratio 1:4). UGIB patients with CAD were significantly older, and had more frequently used antiplatelets and warfarin than in non-CAD patients. Compared with non-CAD, the CAD patients had significantly higher Glasgow-Blatchford score, full and pre-endoscopic Rockall score and full. Peptic ulcer in CAD patients was identified more often than in non-CAD patients. UGIB patients with CAD and non-CAD had similar outcomes with regard to mortality rate, re-bleeding, surgery, embolization, and packed erythrocyte transfusion. However, CAD patients had longer duration of hospital stays than non-CAD patients. Two CAD patients died from cardiac arrest after endoscopy, whereas three non-CAD patients died from pneumonia and acute renal failure during their hospitalization.In Thailand, patients presenting with UGIB, concomitant CAD did not affect clinical outcome of treatment, compared with non-CAD patients, except for longer hospital stay.
Project description:BACKGROUND & STUDY AIMS:Corona virus disease-19 (COVID-19) pandemic has markedly impacted routine medical services including gastrointestinal (GI) endoscopy. We aim to report the real-life performance in high volume GI endoscopy units during the pandemic. PATIENTS AND METHODS:A web-based survey covering all aspects of daily performance in GI endoscopy units was sent to endoscopy units worldwide. Responses were collected and data were analyzed to reveal the effect of COVID-19 pandemic on endoscopy practice. RESULTS:Participants from 48 countries (n = 163) responded to the survey with response rate of 67.35%. The majority (85%) decreased procedure volume by over 50%, and four endoscopy units (2.45%) completely stopped. The top three indications for procedures included upper GI bleeding (89.6%), lower GI bleeding (65.6%) and cholangitis (62.6%). The majority (93.9%) triaged patients for COVID-19 prior to procedure. N95 masks were used in (57.1%), isolation gowns in (74.2%) and head covers in (78.5%). Most centers (65%) did not extend use of N95 masks, however 50.9% of centers reused N95 masks. Almost all (91.4%) centers used standard endoscopic decontamination and most (69%) had no negative pressure rooms. Forty-two centers (25.8%) reported positive cases of SARS-CoV-2 infection among patients and 50 (30.7%) centers reported positive cases of SARS-CoV-2 infection among their healthcare workers. CONCLUSIONS:Most GI endoscopy centers had a significant reduction in their volume and most procedures performed were urgent. Most centers used the recommended personal protective equipment (PPE) by GI societies however there is still a possibility of transmission of SARS-CoV-2 infection in GI endoscopy units.
Project description:<b>Background and study aims</b> ?The COVID-19 pandemic has caused a major disruption in the healthcare system. This study determined the impact of the first wave of COVID-19 on the number and outcome of patients hospitalized for upper gastrointestinal bleeding (UGIB) in Hong Kong. <b>Patients and methods</b> ?Records of all patients hospitalized for UGIB in Hong Kong public hospitals between October 2018 and June 2020 were retrieved. The number and characteristics of patients hospitalized for UGIB after COVID-19 was compared by autoregressive integrated moving average (ARIMA) model prediction and historical cohort. <b>Results?</b> Since the first local case of COVID-19, there was an initial drop in UGIB hospitalizations (observed 29.8 vs predicted 35.5 per week; <i>P</i> ?=?0.05) followed by a rebound (39.8 vs 26.7 per week; <i>P</i> ?<?0.01) with a turning point at week 14 (Petitt's test, <i>P</i> ?<?0.001). There was a negative association between the number of COVID-19 cases and the number of patients hospitalized for UGIB (Pearson correlation -0.53, <i>P</i> ?<?0.001). Patients admitted after the outbreak of COVID-19 had lower hemoglobin (7.5 vs baseline 8.3?g/dL; <i>P</i> ?<?0.01) and a greater need for blood transfusion (64.5?% vs baseline 50.4?%; <i>P</i> ?<?0.01), but similar rates of all-cause mortality (6.9?% vs 7.1?%; <i>P</i> ?=?0.82) and rebleeding (6.7?% vs 5.1?%; <i>P</i> ?=?0.11). There was also a higher proportion of patients with variceal bleeding (10.5?% vs baseline 5.3?%; <i>P</i> ?<?0 .01). <b>Conclusions?</b> There was a dynamic change in the number of patients hospitalized for UGIB in Hong Kong during the first wave of the COVID-19 outbreak, with more obvious impact during the initial phase only.
Project description:INTRODUCTION:There is little evidence about gastrointestinal (GI) disorders in patients with schizophrenia. We examined association of schizophrenia with upper GI bleeding (UGIB) and nonbleeding ulcers and associated risk factors and mortality. METHODS:We used the data linked from population-based registries in Denmark. Among patients with incident schizophrenia in 1980-2011, we computed cumulative incidences and standardized incidence ratios of UGIB, bleeding ulcers, and nonbleeding ulcers compared with the general population; evaluated risk factors for the 3 GI endpoints, including somatic and psychiatric comorbidity; and examined subsequent all-cause mortality. RESULTS:Among 39,998 patients with schizophrenia, the standardized incidence ratios were 2.92 (95% confidence interval (CI), 2.76-3.08) for UGIB, 2.36 (95% CI, 2.15-2.58) for bleeding ulcers, and 2.00 (95% CI, 1.87-2.15) for nonbleeding ulcers. Risk factors for UGIB and nonbleeding ulcers included age, somatic comorbidity, and medication use. UGIB and nonbleeding ulcers were associated with the subsequent increase in mortality. CONCLUSIONS:Schizophrenia is associated with an increased risk of UGIB and nonbleeding ulcers, whose risk factors in patients with schizophrenia are similar to those in the general population.
Project description:Abstract Background Inadequate visualization during upper gastrointestinal bleeding (UGIB) is a common problem. The BioVac direct suction device is designed to enhance endoscopic suction to improve visualization. We initiated a randomized clinical trial to determine the efficacy of this device (NCT02150941). Aims In this report, we present the results of a feasibility analysis. Methods Between July 2014 and June 2016, patients admitted to two academic hospitals undergoing endoscopy for UGIB with suspicion of active bleeding (ie. fresh blood hematemesis, hemodynamic instability, acute drop in hemoglobin) were invited to participate. EGD was performed and patients where the source of bleeding was not found due to poor visualization after 5 minutes were randomized to BioVac or standard endoscopy suction. Due to the difference in suctioning power, a placebo was not possible. Instead, the procedure was recorded and assessed by a blinded outcome assessor. The procedure was otherwise performed at the discretion of the endoscopist without input from the study staff. The primary outcome was whether the bleeding source was found. Secondary outcomes included the mucosa visualization score, endoscopic therapy, need for repeat endoscopy within 7 days, rebleeding, and 30-day mortality. Results Over 24 months, a total of 70 subjects were recruited. 60 subjects were excluded due to the source of bleeding being found within the first 5 minutes or there being no blood in the upper GI tract. Of the 10 subjects randomized, 7 were assigned to standard endoscopy suction and 3 to BioVac. The mean (SD) age was 68.3 (13.4) and 30% were females. 60% presented with fresh blood hematemesis, 30% had a history of cirrhosis, 50% bled as an inpatient, and 60% had an ASA score of ?4. The source of bleeding was found in 66% in the BioVac group and 71% among the controls. The mean (SD) mucosal visualization score was 15.3 (2.6) for BioVac and 7.7 (3.3) for controls although there was no difference in the application of endoscopy therapy (33% in both groups). 33% in the BioVac group and 83% in the control group required a repeat endoscopy within 7 days. No patients rebleed or died in the BioVac group compared to 3 who rebleed and 4 who died in the control. Conclusions Study feasibility is hampered by low recruitment and high exclusion rates. A multi-centre approach to increase recruitment and the development of a better clinical prediction tool for active bleeding are required. Funding Agencies Vantage Endoscopy
Project description:The early use of risk stratification scores is recommended for patients presenting with acute non-variceal upper gastrointestinal (GI) bleeds (ANVGIB). AIMS65 is a novel, recently derived scoring system, which has been proposed as an alternative to the more established Glasgow-Blatchford score (GBS).To validate the AIMS65 scoring system in a predominantly Caucasian population from Scotland and compare it with the GBS.Retrospective study of patients presenting to a district general hospital in Scotland with a suspected diagnosis of ANVGIB who underwent inpatient upper GI endoscopy between March 2008 and March 2013.The primary outcome measure was 30-day mortality. Secondary outcome measures were requirement for endoscopic intervention, endoscopy refractory bleeding, blood transfusion, rebleeding and admission to high dependency unit (HDU) and intensive care unit (ICU). The area under the receiver operating characteristic (AUROC) curve was calculated for each score.328 patients were included. Of these 65.9% (n=216) were men and 34.1% (n=112) women. The mean age was 65.2?years and 30-day mortality 5.2%. AIMS65 was superior to the GBS in predicting mortality, with an AUROC of 0.87 versus 0.70 (p<0.05). The GBS was superior for blood transfusion (AUROC 0.84 vs 0.62, p<0.05) and admission to HDU (AUROC 0.73 vs 0.62, p<0.05). There were no significant differences between the scores with respect to requirement for endoscopic intervention, endoscopy refractory bleeding, rebleeding and admission to ICU.AIMS65 accurately predicted mortality in a Scottish population of patients with ANVGIB. Large prospective studies are now required to establish the exact role of AIMS65 in triaging patients with ANVGIB.
Project description:Description:This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. Methods:An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. Recommendations:Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
Project description:Risk assessment for upper gastrointestinal bleeding (UGIB) is important; however, current scoring systems are insufficient. We aimed to develop and validate a prediction model for rapidly determining the occurrence of hypotension in non-variceal UGIB patients with normotension (systolic blood pressure ?90 mmHg) at emergency department presentation. In this prospective observational cohort study, consecutive non-variceal UGIB patients between January 2012 and April 2017 were enrolled. We developed and validated a new prediction model through logistic regression, with the occurrence of hypotension <24 h as the primary outcome. Among 3363 UGIB patients, 1439 non-variceal UGIB patients were included. The risk factors for the occurrence of hypotension were lactate level, blood in nasogastric tube, and systolic blood pressure. The area under the curve (AUC) of the new scoring model (LBS-Lactate, Blood in nasogastric tube, Systolic blood pressure) in the development cohort was 0.74, higher than the value of 0.64 of the Glasgow?Blatchford score for predicting the occurrence of hypotension. The AUC of the LBS score in the validation cohort was 0.83. An LBS score of ?2 had a negative predictive value of 99.5% and an LBS score of ?7 had a specificity of 97.5% in the validation cohort. The new LBS score stratifies normotensive patients with non-variceal UGIB at risk for developing hypotension.