Introduction

Starting the blood supplementation at a higher haemoglobin threshold (Hgb <90-100 g/L) in upper gastrointestinal bleeding (UGIB) can lead to severe consequences due to volume overload. Previous studies have already shown the benefits of restrictive transfusion (Hgb <70-80 g/L). However, the optimal transfusion threshold and how restrictive transfusion affects short- and long-term outcomes after UGIB remained unanswered.

Aims & Methods

We aimed to assess the efficacy and safety of restrictive compared to liberal transfusion strategies in the GIB population, assessing the source of bleeding and transfusion thresholds separately. We searched PubMed, CENTRAL, Embase, and Web of Science for randomised controlled trials on 15.01.2022 without restrictions. Studies comparing lower to higher RBC transfusion thresholds after GIB were eligible. We used the random effect model and calculated pooled mean differences (MD), risk ratios (RR) and proportions with 95% confidence intervals (CI) to calculate the overall effect size.

Results

The search yielded 3955 hits. All seven eligible studies reported on the upper GIB population. Restrictive transfusion did not increase the in-hospital- (RR:0.94; CI:0.46,1.94) and 30-day mortality (RR:0.68; CI:0.48,0.97). In-hospital- and 28 to 45-day rebleeding rate was also not higher with the restrictive modality (RR:0.67; CI:0.30,1.50; RR:0.75; CI:0.49,1.16, respectively). Results of individual studies showed a lower rate of transfusion reactions and post-transfusion intervention if the transfusion was started at a lower threshold. A haemoglobin threshold >80g/L may result in a higher untoward outcome rate.

Conclusion

In summary, restrictive transfusion proved non-inferior to liberal transfusion regarding all investigated clinical endpoints. The optimal restrictive transfusion threshold should be further investigated.

References

1. Gralnek, I. M., Barkun, A. N. & Bardou, M. Management of acute bleeding from a peptic ulcer. N Engl J Med 359, 928-937; 10.1056/NEJMra0706113 (2008).
2. Jairath, V. et al. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial. LANCET 386, 137-144; 10.1016/S0140-6736(14)61999-1 (2015).
3. Villanueva, C. et al. Transfusion strategies for acute upper gastrointestinal bleeding. New England journal of medicine 368, 11‐21; 10.1056/NEJMoa1211801 (2013).
4. Lee, J. M. et al. Target level for hemoglobin correction in patients with acute non-variceal upper gastrointestinal bleeding. Gastroenterology 146, S-321; 10.1016/S0016-5085(14)61157-4 (2014).
5. Hochain, P. et al. Transfusion for variceal bleeding in cirrhotic patients. Gut 38, 154; 10.1136/gut.38.1.154 (1996).
6. Blair, S. D., Janvrin, S. B., McCollum, C. N. & Greenhalgh, R. M. Effect of early blood transfusion on gastrointestinal haemorrhage. The British journal of surgery 73, 783-785; 10.1002/bjs.1800731007 (1986).
7. Kola, G., Sureshkumar, S., Mohsina, S., Sreenath, G. S. & Kate, V. Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial. SAUDI JOURNAL OF GASTROENTEROLOGY 27, 13-19; 10.4103/sjg.SJG_152_20 (2021).

Introduction

Despite a lack of evidence, patients are often not fed for 48 to 96 hours after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB.

Aims & Methods

The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27^th of August 2023 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model.

Results

A total of 10 trials with 1,051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR: 1.20, CI: 0.85 – 1.71, I² = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR: 0.61, CI: 0.35 – 1.06, I² = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR: 1.04, CI: 0.66 – 1.63, I² = 0% and RR: 1.16, CI: 0.63 – 2.13, I² = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD: - 1.22 days, CI: - 2.43 to - 0.01, I² = 94%).

Conclusion

Compared with DN, EN (within 24 hours) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.

Disclosure

None to declare.

Introduction

Gastrointestinal bleeding is among the most common indications for red blood cell (RBC) transfusion. According to current guidelines, restrictive RBC transfusion initiated at a lower haemoglobin (Hgb) level (<70-80 g/L) is non-inferior to liberal strategy (<90-100 g/L) regarding mortality and rebleeding. Moreover, it results in a lower rate of adverse events and decreases hospital expenses. However, the published randomised controlled trials are not using a unified definition for the restrictive modality.

Aims & Methods

Our analysis aims to assess the efficacy of restrictive transfusion by comparing different Hgb thresholds. Patients enrolled in the Hungarian Gastrointestinal Bleeding Registry who received RBC transfusion during hospitalisation were found eligible. The transfused group was divided into subgroups based on their lowest Hgb level during hospitalisation: ≤60 g/L (group 1), 61-70 g/L (group 2), 71-80 g/L (group 3), ≥80 g/L (group 4). Patients with recurrent bleeding were excluded. The outcomes examined included in-hospital mortality, the need for surgical intervention, intensive care therapy, and length of hospital stay. When comparing the groups, group 2 was used as the reference. Adjusted odds ratios (aOR) were calculated using binominal logistic regression, while the ANOVA test was used to determine adjusted mean differences (MD) and the related 95% confidence intervals (CI). The multivariate model included age >65 years, sex, ischemic heart disease, vascular disease, heart failure, chronic obstructive pulmonary disease, active malignancy, antithrombotic and anticoagulant treatment.

Results

Of 1019 patients with gastrointestinal bleeding, 575 (56.42%) were eligible for analysis. The lowest mortality rate was observed in group 3 (8.98%). However, there was no statistically significant difference in mortality odds when comparing transfusion at different Hgb levels to group 2 (1 vs 2: aOR: 0.64, CI: 0.24-1.70; 3 vs 2: aOR: 0.79, CI: 0.27-2.27; 2 vs 4: aOR: 0.50, CI: 0.10-2.48). Group 2 had the slightest need for surgical intervention (2.30%) compared to other groups. There was a tendency towards increased odds of surgical intervention in group 1 compared to group 2 (aOR: 4.13, CI: 0.64-26.65). Furthermore, the odds of intensive care therapy were significantly increased in groups 1 and 4 compared to group 2 (1 vs 2: aOR: 6.37, CI: 1.37-29.53; 4 vs 2: aOR: 10.97, CI: 1.91-62.98). Compared to group 2, group 3 showed an increased tendency in the odds for intensive care unit admission (aOR: 4.83, CI: 0.97-24.07). There was no significant difference in the length of hospital stay among the groups.

Conclusion

Our findings support that haemoglobin levels between 61-70 g/L may be considered safe compared to lower (≤60 g/L) or higher (≥80 g/L) transfusion thresholds. Randomised controlled trials with extended follow-up periods are needed to validate our results.

Introduction

Despite lack of evidence, patients are kept nil by mouth for 48 to 96 hours after upper gastrointestinal bleeding (UGIB) due to fear of rebleeding. However, many trials have demonstrated the benefits of early nutrition after UGIB. We conducted a meta-analysis of randomized controlled trials to evaluate the safety and outcomes of early nutrition compared to delayed nutrition after UGIB.

Aims & Methods

The protocol was registered on PROSPERO in advance (CRD42022372306). Five databases (PubMed, Embase, CENTRAL, Scopus, and Web of Science) were searched on the 10th of November 2022 to identify randomized controlled trials that met our eligibility criteria. In-hospital and 30-day outcomes were pooled separately. Mortality rate, rebleeding rate, and length of hospital stay were the primary outcomes. The pooled risk ratio (RR), mean difference (MD), and the corresponding 95% confidence interval (CI) were calculated using a random effects model.

Results

A total of 10 trials with 1,051 patients were included in the analysis. Comparing the two groups, 7-day mortality showed no significant difference (RR=1.23, CI: 0.72 - 2.10), while there was a clear tendency for a decrease in 30-day mortality in the early nutrition group (RR=0.57, CI: 0.31 – 1.04). As for 7-day and 30-day rebleeding, there was no statistically significant difference between the two groups (RR=1.05, CI: 0.63 – 1.74 and RR=1.16, CI: 0.59 – 2.26, respectively). In addition, our analysis showed that the early nutrition group needed a reduced length of hospital stay compared to the delayed nutrition group (MD= - 1.22, CI: -2.43 to -0.01).

Conclusion

Compared with delayed nutrition, early nutrition appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications regarding rebleeding or mortality after upper gastrointestinal bleeding.

Disclosure

The authors declare no potential conflict of interest.

Introduction

Acute gastrointestinal bleeding (GIB) is a common reason for hospitalization, with a 2%–20% risk of mortality. Identification of patients at high risk of death is essential to make fast and adequate decisions on their management.

Aims & Methods

We developed two machine-learning (ML) models to calculate the risk of in-hospital mortality in patients admitted due to overt GIB.
The prospective, multicenter Hungarian GIB Registry's data were analyzed. We focused on in-hospital mortality and applied statistical binary classification. The predictive performance of XGBoost and Catboost machine-learning algorithms was compared with the Glasgow-Blatchford (GBS) and pre-endoscopic Rockall scores. We evaluated our models using five-fold cross-validation, and performance was measured by area under receiver operating characteristic curve (AUC) analysis with 95% confidence intervals (CI). The individual predictions and the variables' contribution to the outcome were calculated via the SHapley Additive exPlanations (SHAP) method.

Results

Overall, we included 1,021 patients in the analysis; 52% had nonvariceal upper GIB, 30% had lower GIB, and 9% had variceal bleeding. The median age was 70 years; 60% were men. In-hospital death occurred in 108 cases (11%). We selected 19 of 96 input variables in both final ML models. The XGboost and the Catboost model identified patients who died with an AUC of 0.84 (CI: 0.76-0.90; 0.77-0.90; respectively) in the internal validation set, whereas the GBS and pre-endoscopic Rockall clinical scoring system's performance was significantly lower, AUC values of 0.68 (CI: 0.62 - 0.74) and 0.62 (CI: 0.56 - 0.67), respectively. The XGBoost model had a specificity of 0.96 (CI: 0.92-0.98) at a sensitivity of 0.25 (CI: 0.10-0.43) compared with the CatBoost model, which had a specificity of 0.74 (CI: 0.66-0.83) at a sensitivity of 0.78 (CI: 0.57-0.95). In the CatBoost model, the most influential variables contributing to the prediction were CRP level, smoking, melena, minimum systolic blood pressure, previous GIB, Glasgow Coma Scale and hemoglobin level.

Conclusion

The new ML models identified patients with high mortality risk significantly better than GBS and pre-endoscopic Rockall scores. Due to its better sensitivity, we prefer the CatBoost model in determining the in-hospital mortality risk of GIB.

Introduction

Upper gastrointestinal bleeding (UGIB) poses a significant threat in patients presenting to the emergency department, particularly in those with associated hemodynamic instability. Despite major advancements in medical and endoscopic therapeutic options, mortality rates have not shown a substantial decline over the years. This study aimed to assess clinical practice patterns in order to gain a clearer understanding of the pre-endoscopic assessment for patients with acute UGIB.

Aims & Methods

This study was an international online survey based on a prospective two-phase data collection approach, conducted between April 2023 and November 2023. The survey targeted practicing physicians actively involved in managing patients with UGIB. Data collection and management were performed through Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey comprised four key domains: demographics and clinical practice, definitions of hemodynamic instability, pre-endoscopic assessment, and optimal timing of endoscopy, encompassing a total of 33 questions. The primary analysis provided a descriptive assessment of responses reported as proportions. Secondary analyses explored differences in responses based on years of clinical experience, practice setting, and the estimated annual number of UGIB cases encountered

Results

A total of 533 clinicians from 50 countries completed our survey. Among respondents, 54.6% work in university-based hospitals, and 67.7% reported managing over 100 UGIB patients annually. Regarding clinical experience, 55.7% have less than 10 years, with 44.3% with over 10 years of experience. Only 47.1% of respondents reported that their hospitals implement a triage system for UGIB patients. Additionally, 39.6% indicated that they do not use any risk stratification scores at the time of patient presentation. For initial fluid resuscitation, 0.9% saline (40.9%) and balanced crystalloid fluids (39.5%) were almost equally preferred. The rate of fluid resuscitation was reported to depend on the patient’s hemodynamic status by 40.2% of respondents. Most respondents indicated that hemodynamically unstable patients are primarily managed in the emergency department or intensive care unit. A total of 34.3% of respondents indicated that they do not routinely use prokinetics prior to endoscopy in UGIB patients, while 27.6% reported not commonly using them even in cases involving severe bleeding or known gastric emptying disorders. Proton pump inhibitors are administered prior to upper GI endoscopy in all cases by 70.4% of respondents, while vasoconstricting agents are used by 61% in cases of suspected variceal bleeding.

Conclusion

Our survey found considerable variability among respondents regarding the pre-endoscopic management of patients presenting with upper gastrointestinal hemorrhage. The overall adherence to international guidelines was low, which can potentially result in a significant negative impact on patient outcomes.

Introduction

Restarting anticoagulation (AC) therapy following acute gastrointestinal bleeding (GIB) is a multidisciplinary, personalized decision. Current guidelines recommend resuming AC, though data on the optimal timing is limited.

Aims & Methods

Our aim is to assess the short-term effect of early and delayed AC therapy resumption.
We analyzed the data of the Hungarian GIB Registry (a multicenter, prospective database) between 2019-2022. Patients were included after successful management of AC-related GIB. Detailed medical and drug history, demographics, and data on the index bleeding and management (bleeding source, endoscopic, and medical therapy) were collected. 30 and 90-day rebleeding, thromboembolic (TE) complications, all-cause, and 30-day recurrent GIB or TE-related mortality were assessed in the early (≤ 7 days) and delayed (>7 days) AC resumption groups.

Results

218 cases were analyzed. Except for the CHA₂Ds₂-VASc score (mean (SD) 5.19 (1.65) vs 4.37 (1.549); p=0.02), the main characteristics (e.g., age, Charlson comorbidity index, active malignancy, anamnestic previous GIB, co-medications, HAS-BLED score, hemodynamic instability, high-risk bleeding site, endoscopic intervention) were similar between the two groups. Delayed AC therapy resumption was not associated with decreased 30-day rebleeding risk (5.3% vs. 6.7%; HR = 1.26, 95%CI 0.27-5.77, p=0.76). Delayed resumption was not associated with a higher 90-day TE complications rate (2.1% vs. 6.6%; HR = 3.17, 95%CI 0.58-17.33, p=0.18). Recurrent GIB-related 30-day mortality occurred only in one case (early resumption group, 12 days after admission with index bleeding). TE-related mortality was not observed during the follow-up.

Conclusion

Anticoagulation resumption in the first seven days after GIB was proven to be safe, which supports the suggestion of the actual European guidelines. Further research on separated bleeding sources and types of anticoagulants is needed.

Disclosure

Authors do not have any conflict of interest to disclose.