upper gastrointestinal bleeding

Assessing the Risk for Treating Upper GI Bleeding in Hospitalized Patients.

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The Glasgow-Blatchford score was superior to the Rockall score in predicting the need for transfusions or surgery in patients admitted for UGIB, but use of any risk stratification system is still of primary importance.
The Glasgow-Blatchford score (GBS) is commonly used to distinguish patients with upper gastrointestinal bleeding (UGIB) who are at low versus high risk for rebleeding or death from endoscopy. The Rockall score (RS) has been widely used both before and after endoscopy to stratify patients according to their risk for mortality. Now, researchers in Australia have compared the performances of these tools in predicting the need for interventions and clinical outcomes in 708 patients hospitalized for UGIB who underwent urgent endoscopy.

Compared with post-endoscopy RS and GBS, pre-endoscopy RS was less effective in predicting the need for endoscopic therapy (area under the curve, 0.76 and 0.76 vs. 0.66, respectively). Compared with the full RS and GBS, pre-endoscopy RS was less effective in predicting rebleeding (AUC, 0.64 and 0.71 vs. 0.57, respectively). Compared with both pre-endoscopy RS and post-endoscopy RS, the GBS more accurately predicted the need for both blood transfusion (AUC, 0.70 and 0.68 vs. 0.81, respectively) and surgery (AUC, 0.64 and 0.51 vs. 0.71, respectively).

COMMENT

The authors conclude that the Glasgow-Blatchford score is as accurate as the full Rockall score in predicting rebleeding and the need for endoscopic therapy and superior to the RS in predicting the need for transfusions or surgery in patients hospitalized for upper gastrointestinal bleeding. The results of this study may be affected by the inclusion of patients with variceal bleeding, the unblinded decisions of physicians on the need for endoscopy and transfusions, and the absence of posthospitalization follow-up. Also, the authors used a higher GBS cutoff value for interventions than that used in previous studies (3 vs. 1). Nonetheless, these results support those of multiple studies in which the efficacy of both the GBS and RS in risk stratification of patients with upper gastrointestinal bleeding, as well as that of a simplified system called AIMS65, have been demonstrated (NEJM JW Gastroenterol Feb 22 2013 and NEJM JW Gastroenterol Dec 9 2011). Overall, I believe that the importance of using any risk stratification tool in this setting is still of primary concern compared with the question of which scoring system to use.

Source: NEJM

Comparing Scoring Systems to Predict Outcomes in Upper Gastrointestinal Bleeding.

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AIMS65 better predicted mortality and Glasgow-Blatchford better predicted the need for transfusion, but both scoring systems can be helpful in identifying high-risk patients with UGIB.

Investigators recently derived and validated AIMS65 — a new scoring system to predict outcomes for patients with acute upper gastrointestinal bleeding (UGIB) — using a large population of patients from 187 U.S. hospitals (JW Gastroenterol Dec 9 2011).

Now, the researchers have revalidated AIMS65 using data on 278 UGIB patients from a tertiary-care hospital who had a higher severity of disease than that observed in the original population. They also compared the performance of AIMS65 with that of the Glasgow-Blatchford system (GBS; JW Gastroenterol Jul 29 2011) in predicting the primary outcome of inpatient mortality and several secondary outcomes: the composite endpoint of mortality, rebleeding, and endoscopic, radiologic, or surgical intervention; transfusion requirement; intensive care unit admission; rebleeding; length of hospital stay; and the timing of endoscopy.

Overall inpatient mortality was 6.5%. The composite endpoint was seen in 35%. AIMS65 was superior to GBS for predicting mortality (area under the receiver operating curve, 0.93 vs. 0.68; P<0.001), but GBS was superior for predicting the need for transfusion (AUROC, 0.85 vs. 0.65; P<0.01). The two systems were similarly accurate for predicting and other secondary outcomes. GBS values of 10 and 12 maximized the accuracy for predicting mortality and rebleeding, respectively. AIMS65 values of ≥2 maximized the accuracy for predicting both outcomes.

Comment: Results of this study from a tertiary-care hospital with expertise in treating patients with upper gastrointestinal bleeding might not be generalizable to other settings. What seems clear from the evidence regarding UGIB scoring systems is that shock, advanced age, and comorbid conditions used in any scoring system can identify patients at high risk for adverse outcomes. However, the issue is not about which system is better; rather, it is about ensuring that some system is used to identify high-risk patients, who will benefit from urgent endoscopy, endoscopic therapy, and more aggressive care, and low-risk patients, who can be treated as outpatients.

Source: Journal Watch Gastroenterology

 

Preventing Upper Gastrointestinal Bleeding in Patients with Acute Coronary Syndrome.

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A proton-pump inhibitor was superior to an H2-receptor antagonist..

Patients with acute coronary syndrome (ACS) or ST-segment-elevation myocardial infarction (STEMI) are often treated with a combination of antithrombotics plus anticoagulants or thrombolytics. However, these drugs might increase the risk for upper gastrointestinal bleeding (UGIB). The optimal treatment approach to minimize this risk has not been prospectively studied.

Now, investigators in Hong Kong randomized 313 patients hospitalized for ACS or STEMI to receive 20 mg of esomeprazole or 40 mg of famotidine in a double-blind study. Participants were being treated with aspirin, clopidogrel, and enoxaparin or thrombolytics. Patients were followed for occurrence of UGIB.

Follow-up ranged from 4 to 52 weeks, with a mean of 19.0 weeks for the esomeprazole group and a mean of 17.8 weeks for the famotidine group. Only one patient developed UGIB in the esomeprazole group, compared with nine patients in the famotidine group (hazard ratio, 0.095; 95% confidence interval, 0.005–0.504).

Comment: The authors conclude that esomeprazole is superior to famotidine in preventing UGIB in patients with ACS or STEMI receiving antiplatelet plus anticoagulant or thrombolytic therapy. The results of this study are consistent with prior findings that proton-pump inhibitor (PPI) therapy can reduce UGIB in patients taking aspirin and clopidogrel . PPIs also seem effective when the added risk from therapy with enoxaparin or thrombolytics is present. The superiority of a PPI to an H2-receptor antagonist is also consistent with prior studies about the prevention of UGIB in high-risk patients. Cotherapy with a PPI should be considered in ACS and STEMI patients who are receiving dual therapy.

Source: Journal Watch Gastroenterology

Tranexamic acid for upper gastrointestinal bleeding.

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Tranexamic acid reduces haemorrhage through its antifibrinolytic effects. In a previous version of the present review, we found that tranexamic acid may reduce mortality. The present review includes updated searches of randomised trials on tranexamic acid versus placebo, cimetidine or lansoprazole.
OBJECTIVES: To assess the effects of tranexamic acid for upper gastrointestinal bleeding. SEARCH
METHODS: Electronic searches (The Cochrane Library, MEDLINE, EMBASE, Science Citation Index) and manual searches were combined. The last search update was in October 2011.
SELECTION CRITERIA: Trials in which patients with upper gastrointestinal bleeding were randomised to receive either tranexamic acid or placebo, or any anti-ulcer drug, were included.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. All-cause mortality was the primary outcome measure. Random-effects model meta-analyses were performed and results presented as relative risks (RR) with 95% confidence intervals (CI). Subgroup, sensitivity, regression and sequential analyses were performed to analyse sources of intertrial heterogeneity and the robustness of the overall result.
MAIN RESULTS: Seven double blind randomised trials on tranexamic acid versus placebo, cimetidine, or lanzoprazole were included. One trial offered endoscopic treatment to all patients that were randomised. Random-effects model meta-analysis found that tranexmic acid reduced mortality compared with placebo (41 of 829 versus 68 of 825 patients; RR: 0.61, 95% CI 0.42 to 0.89). The beneficial effect was not confirmed in subgroup analysis stratified for the quality of bias control, in worst case scenario analyses (in which 21% of the randomised patients were excluded), or in sequential analyses. No significant differences were found between tranexamic acid and placebo on bleeding, surgery, or transfusion requirements. No clear effects of tranexamic acid were identified in trials using endoscopic therapy or in the trials comparing tranexamic acid with cimetidine or lansoprazole. In the tranexamic acid group, five cases of serious thromboembolic events occurred (myocardial infarction, pulmonary embolism, and cerebral infarction). Overall, the number of patients with any thrombotic event was not significantly increased in the tranexamic acid group (RR 1.87, 95% CI 0.60 to 5.85).
AUTHORS’ CONCLUSIONS: Considering the internal and external validity of the evidence, tranexamic acid cannot be recommended for routine use. Additional trials in which tranexamic acid is used in combination with the currently recommended interventions are required.

Source:Cochrane library.