Introduction

Gastrointestinal bleeding is a life-threatening emergency associated with high morbidity and mortality requiring close monitoring and early endoscopic intervention to diagnose and treat the bleeding. The "weekend effect" often leads to concerns of delay or inappropriate management due to the usual lack of medical and paramedical staff and suggesting an additional risk and increased mortality.

Aims & Methods

The aim of our study was to investigate outcomes of non-variceal bleeding (NVB) occurring during the week-end. We conducted a retrospective, single-center analysis of clinical and endoscopic data of all patient hospitalized for NVB between 2015 and 2023 from our hospital's computerised medical record database. Data over timing of endoscopy, therapeutic management, hospital stay and mortality were collected depending on whether the digestive bleeding occurred at the weekend (G1) or during the week (G2).

Results

A total of 91 patients were enrolled: 58 men and 33 women with a sex ratio of 1.75 and an average age of 63.9 (20-91). The two groups were comparable in terms of the mean time taken to perform upper GI endoscopy (G1:11.9 hours vs G2:15.9 hours, p=0.06) or a colonoscopy (G1:39.94 hours vs G2:49.15 hours, p=0.11). However, there was a slight increase in the need for an endoscopic haemostasis procedures in the weekend group p=0.05. Nevertheless, there was no significant difference between the two groups in terms of total length of hospital stay (G1:7.19 days vs. G2:7.54 days, p=0.65), transfusion requirements for red blood cells (RBCs) (G1: 3,33 vs. G2:2.3, p=0.07) and the use of catecholamines to maintain an optimal hemodynamic state (p=0.51). In addition, there was no significant difference regrading overall mortality between the weekend and the weekday groups (G1: 5% vs G2:12.9% respectively, p=0.25).

Conclusion

There is no evidence of the "weekend effect" in our study, as the clinical management and outcomes were independent of the day of admission with no subsequent increase of mortality during NVB. This reflects a continuous development and a better access to interventional endoscopy, and a multidisciplinary collaboration overcoming the logistical and technical difficulties often encountered during the weekend.

Introduction

Gastrointestinal (GI) hemorrhage remains the most common emergency in digestive endoscopy. However, its management is often tricky given the different etiopathogenic and clinical profiles associated with it. There is a tendency to believe that GI bleeding is often more detrimental in patients on anti-platelet aggregation and/or anticoagulation because of the altered physiological hemostasis and the risk of flare-up of the underlying disease justifying their use.

Aims & Methods

The aim of our study was to investigate the epidemiological, clinical profile and outcomes of gastrointestinal bleeding occurring in this particular context. We conducted a retrospective comparative study including patients hospitalized for GI bleeding between 2015 and 2023. Patients were divided into two groups according to whether they were on antithrombotic therapy (platelet and/or oral anticoagulation) (G1) or not (G2). We have excluded patients with portal hypertension related bleeding and patients with inherited blood disorders. Clinico-biological, therapeutic data and outcomes were collected and compared between the two groups.

Results

Of the 91 patients enrolled with a sex-ratio of 1.84, 52 were on anti-platelet agents and/or oral anticoagulants. The mean age was significantly higher in patients under anti-thrombotic treatment (G1: 70 vs G2: 56 years, p<0.0001). The two groups were comparable in terms of gender, systolic blood pressure, hemoglobin levels. However, G1 patient showed higher levels of CRP (G1: 38.8 vs G2: 25.86 mg/dl, p=0.04) and plasma urea (G1: 12,8 vs G2: 9,3 mmol/l, p=0.02). The main cause of bleeding in both groups was peptic ulcer disease. Nevertheless, lower GI bleeding was significantly more frequent in the first group (p=0.03), with the main etiology in this context being diverticular hemorrhage (p=0.01). There was no significant difference in the number of red blood cells (RBCs) transfused, the time taken to perform GI endoscopy, the use of a particular endoscopic hemostasis technique and the number of sessions required to control the bleeding between the two groups. Patients under anti-thrombotic therapy were significantly more likely to be explored by colonoscopy (p=0.01), to have longer mean hospital stay (G1: 8 vs G2: 5 days, p=0.03), without any increase in hemodynamic disorders or infectious complications. Similarly, there was no increase in the need for catecholamines, intensive care unit admission or in mortality rates noted in G1 patients (p >0.05). Finally, the rate of distant bleeding recurrence was slightly similar in the two groups (G1: 13,4 vs G2: 17,9 %, p> 0.05)

Conclusion

Although the occurrence of digestive bleeding is a severe adverse event in patients undergoing antithrombotic therapy due to a precarious underlying condition, there were no major differences regarding outcomes when compared with patients without anti-thrombotic therapy. This reflects a better knowledge of the guidelines regulating the use of these drugs with a better assessment of the bleeding/clotting balance and the improvement of endoscopic hemostasis management.

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGI) represents a significant gastrointestinal disorder with elevated mortality rates (1). Non-steroidal anti-inflammatory drugs (NSAIDs) have been firmly established as a risk factor for NVUGI, yet their precise impact on clinical outcomes remains insufficiently defined (2,3). Conversely, proton pump inhibitors (PPIs) have shown efficacy in reducing the incidence of NVUGI associated with NSAIDs. However, the extent of their influence on the clinical outcomes of NVUGI remains inadequately substantiated. Therefore, it is necessary to study the impact of these drugs on the clinical outcomes of patients with NVUGI.

Aims & Methods

The primary objective of our study is to compare the outcomes of NVUGI patients using NSAIDs with or without PPIs against those who did not use either medication. We conducted a retrospective analysis at a Spanish tertiary hospital, encompassing NVUGI cases from 2013 to 2022. NVUGI was defined as hematemesis or melena accompanied by a two-point decrease in hemoglobin or hemodynamic instability. Key clinical outcomes included the necessity for intervention (endoscopic, radiological, or surgical) and in-hospital mortality. Additionally, we compared baseline characteristics and pertinent clinical results such as rebleeding and delayed cardiovascular events. Statistical analysis was performed using SPSS.

Results

​A total of 1200 cases were included, with 6.6% undergoing concomitant treatment with PPIs and NSAIDs, and 15.7% utilizing NSAIDs alone. Patients who took NSAIDs alone were younger (57 years vs. 66 in both other groups) and had a lower rate of comorbidities. Table 1 presents risk scores and outcome comparisons among the three groups. Statistical differences were observed, revealing lower acute mortality (9.6% vs. 7 vs. 2.8%, p=0.011) and reduced need for intervention (74% vs. 69.6 vs. 57.8%, p<0.001) in the group using NSAIDs alone. In multivariate analysis, MAP(ASH) > 2 (OR: 8, CI: 3-21, p<0.001) and ASA > 2 (OR: 4.4, CI: 1.7-11.4, p:0.002) emerged as independent risk factors for acute mortality, with an elevated MAP(ASH) score (OR: 8.8, CI: 5.9-13, p<0.001) being the sole independent factor explaining the need for intervention.

Conclusion

Patients abstaining from NSAIDs or those concurrently undergoing PPI therapy exhibited a higher incidence of intervention or acute mortality compared to those solely using NSAIDs. Through multivariate analysis, our study indicates that bleeding severity and baseline comorbidities, expressed by elevated MAP(ASH) scores and ASA classification, are pivotal factors influencing the clinical outcomes of NVUGI. In summary, the use of NSAIDs or PPIs to safeguard against gastrointestinal lesions induced by these drugs did not demonstrate a discernible impact on the short-term outcomes of patients with non-variceal upper gastrointestinal bleeding.

References

1. Lakatos L, Gonczi L, Lontai L, Izbeki F, Patai A, Racz I, et al. Incidence, predictive factors, clinical characteristics and outcome of non-variceal upper gastrointestinal bleeding – a prospective population-based study from hungary. Journal of Gastrointestinal and Liver Diseases. 2021 Sep 1;30(3):327–33.
2. Durak MB, Şimşek C, Yüksel İ. Clinical Outcomes of Older Patients with Non-Variceal Upper Gastrointestinal Bleeding Taking Anti-Thrombotic or Non-Steroidal Anti-Inflammatory Agents. Turkish Journal of Gastroenterology. 2023 Sep 1;34(9):918–24.
3. Åhsberg K, Höglund P, Kim WH, Von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol. 2010 Dec;45(12):1404–15.

Introduction

Antiplatelets and anticoagulants significantly increase the risk of upper gastrointestinal bleeding by impairing normal clotting mechanisms. Patients on dual or combined therapy often present with more severe bleeds and poorer endoscopic control. This leads to higher rates of rebleeding, complications, and mortality compared to those not on these therapies.

Aims & Methods

To evaluate the risk and outcomes of non-variceal upper gastrointestinal bleeding (UGIB) in patients on single antiplatelet therapy, dual antiplatelet therapy, and combined antiplatelet-anticoagulant therapy, and to assess associated morbidity, mortality, and rebleeding rates.
A prospective study was conducted involving 150 patients (90 males, 60 females) aged 40–60 years, presenting with upper GI bleeding between 1st January 2023 till 1st January 2025. Patients had co-morbid conditions including hypertension, diabetes mellitus, coronary artery disease, or prior cerebrovascular events, and were on their respective medications for at least 3 months. Patients using NSAIDs, having liver disease, or known bleeding disorders were excluded. Clinical presentations included melena, hematemesis, or both. All patients underwent upper GI endoscopy, with Forrest classification used to characterize ulcers. Laboratory investigations included CBC, LFTs, renal function, PT, and APTT. Bleeding profiles and endoscopic outcomes were analyzed across three medication groups: single antiplatelet (n=60), dual antiplatelet (n=50), and combined antiplatelet-anticoagulant therapy (n=40).

Results

UGIB was reported in 6 (10%) of the single antiplatelet group, 16 (32%) of the dual antiplatelet group, and 14 (35%) of the combined therapy group. Endoscopic findings predominantly revealed Forrest class IIA ulcers. Patients on dual or combined therapy had poorer endoscopic hemostasis. Four patients experienced rebleeding refractory to standard endoscopic measures, requiring angioembolization. One mortality was recorded in the dual antiplatelet group due to massive bleeding and shock.

Conclusion

Dual antiplatelet and combined antiplatelet-anticoagulant therapies significantly increase the risk and severity of non-variceal UGIB, with higher rates of poor endoscopic hemostasis, rebleeding, and mortality. These findings underscore the importance of risk stratification and prophylactic strategies in patients requiring long-term antithrombotic therapy.

References

1. Hao, W., Liu, A., Zhu, H. et al. Risk factors and management of gastrointestinal bleeding in patients with or without antiplatelet and anticoagulation therapy: a multicenter real-world prospective study. BMC Gastroenterol 24, 155 (2024). https://doi.org/10.1186/s12876-024-03238-3
2. Risk of Gastrointestinal Bleeding Increases With Combinations of Antithrombotic Agents and Patient Age Abraham, Neena S. et al. Clinical Gastroenterology and Hepatology, Volume 18, Issue 2, 337 - 346.e19

Introduction

Alcohol abuse is a significant risk factor for the development of hepatic cirrhosis, which can lead to upper gastrointestinal bleeding. In non-cirrhotic patients, alcohol has been studied as a risk factor for non-variceal upper gastrointestinal bleeding (NVUGI), particularly in cases of peptic ulcer bleeding (1). However, the clinical impact of alcohol abuse on outcomes remains unclear. Only one retrospective study has analyzed this, finding an increased risk of rebleeding and non-significant increased mortality among alcohol consumers (2). Nevertheless, this study included cirrhotic patients, who accounted for most of the mortality. There is currently no available data on the impact of alcohol on NVUGI outcomes in non-cirrhotic patients.

Aims & Methods

This study aims to determine the impact of alcohol consumption on clinical outcomes in NVUGI.
We conducted a retrospective analysis at a Spanish tertiary hospital, encompassing NVUGI cases from 2013 to 2022. Alcohol abuse was defined as daily alcohol intake exceeding 20g. Key clinical outcomes included the need for intervention (transfusion, endoscopic, radiological, or surgical) and in-hospital mortality. In addition, we compared baseline characteristics and assessed both acute and delayed 6 months outcomes, including rebleeding and delayed cardiovascular events. Statistical analysis was performed using SPSS.

Results

A total of 892 cases were included. The alcohol abuse group had a higher proportion of men (95.6% vs. 64.1%, p < 0.001) and were younger (median age of 56 years vs. 66 years, p < 0.001). Non-alcohol consumers had more comorbidities and a higher ASA comorbidity risk score (58% had ASA 3 or 4 vs. 46% in the other group, p = 0.015). Additionally, the MAP(ASH) score was higher in the first group (>2 in 54.5% vs. 46.3%, p = 0.030). We did not find any other differences between groups, neither in key outcomes nor in the remaining comparisons for the acute episode. However, delayed mortality (8,2% in group 1 vs 3,1% in group 2, p=0,046) and six months cardiovascular events (8,9% vs 2,3%, p=0,011) were more frequent in the non-alcohol group. In multivariate analysis, only ASA 3-4 (OR: 4.17, CI: 1.49-11.68, p= 0.006) and MAP(ASH) (OR: 7.61, CI: 2.54-22.8, p < 0.001) were found to be independent risk factors for acute mortality.

Conclusion

Alcohol abuse is more common among younger individuals with fewer comorbidities. This consumption does not worsen clinical outcomes in non-cirrhotic NVUGI patients, with similar rates of need for intervention or mortality. Our results indicate that only comorbidities and bleeding severity (summarized as high ASA score and MAP(ASH)) score influence the outcomes. In summary, while alcohol consumption may increase the risk of NVUGI incidence, it does not impact acute outcomes.

References

1. Kelly JP, Kaufman DW, Koff RS, Laszlo A, Wiholm BE, Shapiro S. Alcohol consumption and the risk of major upper gastrointestinal bleeding. Am J Gastroenterol. 1995 Jul;90(7):1058-64.
2. Kärkkäinen JM, Miilunpohja S, Rantanen T, Koskela JM, Jyrkkä J, Hartikainen J, Paajanen H. Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci. 2015 Dec;60(12):3707-15

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a frequent emergency, with a 30-day mortality rate nearing 10%.¹ Although several studies^2-4 have shown the mortality benefits of a specialized pre- and post-endoscopy care model within a Hematemesis and Melaena (H&M) unit, this data is outdated, and the model is resource-intensive. Many hospitals now use a 'shared care' approach, involving both gastroenterology and general medicine for pre-endoscopy management and referral for specialized care post-procedure. Our study aimed to evaluate the impact of a dedicated H&M Unit on the 30-day mortality rate and morbidity, in NVUGIB patients.

Aims & Methods

A retrospective case-control study was conducted with patients admitted for NVUGIB from April to October 2024 at two tertiary hospitals in Western Australia. One hospital, referred to as Hospital #1 (“H-1”), served as the control group, providing pre-endoscopy care through the general medicine unit with specialist gastroenterology input, while the gastroenterology team managed post-endoscopy care. The other hospital, referred to as Hospital #2 (“H-2”), served as the case group and managed both pre- and post-endoscopy care through a dedicated specialist H&M Unit. The study comprised consecutive adult patients aged 16 years and above, with endoscopically confirmed NVUGIB who presented with haematemesis and/or melaena. Patients were excluded if they experienced variceal bleeding or if their NVUGIB occurred during hospitalization for another medical condition. The primary outcome measured was 30-day mortality. Secondary outcomes included: a) time to endoscopy, b) total hospital length of stay (LOS) related to the index bleed and any rebleeds, c) the proportion of patients requiring laparotomy, and d) the total number of packed red blood cell (PRBC) units transfused for the index and any subsequent rebleeds.

Results

The preliminary analysis included 317 patients: 211 (66.6%) from H-1 and 106 (33.4%) from H-2. Patients from H-1 were significantly older [median age (IQR): 73 (62-79) vs 66 (50-76) yrs, p=0.002], had a higher median Glasgow-Blatchford Score (GBS) [9 (7-12) vs 8 (6-10), p <0.001] and a numerically higher median Charlson’s Comorbidity Index (CCI) [(5 (3-7) vs 4 (1.8-6), p = 0.173]. Anticoagulation and NSAID use were similar between the two groups. The unadjusted 30-day mortality rate was higher in H-1 compared to H-2 (3.8% vs. 2.8%, p= 0.04); however, after adjusting for age, gender, CCI, GBS, and time to endoscopy by logistic regression analysis, the difference was no longer significant (p = 0.9). The median time to endoscopy was longer in H-1 compared to H-2 [25.4 hours (17.6-43.8) vs 15.3 hours (8.1-21.7), p < 0.001), with a lower percentage of patients undergoing the procedure within 24 hours (47.9%, vs 83% vs. p < 0.001). The total number of PRBC units transfused was numerically higher in H-1 compared to H-2 [2 (0-3) vs 1 (0-2) unit vs. p = 0.056]. There were numerically more emergency laparotomies in H-1 compared to H-2 [4 (1.9%) vs. 0 (0%), p = 0.15). The median LOS was not significantly different between the two groups [3.8 days (2.4-6.1) vs. 3.6 days (2.4-5.6), p = 0.42].

Conclusion

While the 30-day mortality rate was comparable between the two hospitals, patients from the H&M unit showed lower morbidity, including a reduced transfusion requirement and fewer emergency laparotomies. Additionally, patients from the H&M unit were more frequently endoscoped within the internationally recognized 24-hour time frame, which is an important quality care indicator.

References

1. In KR, Oh YE, Moon HS, et al. Comparison and validation of several scoring systems for non-variceal upper gastrointestinal bleeding: a retrospective study. Sci Rep. 2024; 14:27940. doi:10.1038/s41598-024-79643-1.
2. Sanders DS, Perry MJ, Jones SG, et al. Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation. Eur J Gastroenterol Hepatol 2004; 16:487–94
3. Sanderson JD, Taylor RF, Pugh S, et al. Specialized gastrointestinal units for the management of upper gastrointestinal haemorrhage. Postgrad Med J 1990; 66:654– 6.
4. Kohn A, Ancona C, Belleudi V, et al. The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal haemorrhage: an Italian population-based study. Dig Liver Dis 2010; 42:629–34.

Introduction

Upper digestive hemorrhage (HDH) is a frequent reason for hospitalization in the emergency department. Schematically, they are divided into HDH of varicose origin and HDH of non-varicose origin.
Upper GI endoscopy must be performed as quickly as possible, under the best possible technical conditions.
The objective of our study is to evaluate the hemostatic endoscopic management of these hemorrhages in the emergency department.

Aims & Methods

This is a retrospective descriptive study covering a period of 26 months, from January 2022 to March 2024, and including all patients admitted in an emergency for upper digestive haemorrhage of non-variceal origin, identified during the endoscopy on-call duty at the "Médecine B" Hepato-gastroenterology and Proctology Department, CHU Ibn Sina.
All patients underwent clinical examination, blood count and oeso-gastro-duodenal fibroscopy (FOGD).
Patients admitted for HDH of varicose origin or with normal FOGD were excluded from our study.

Results

91 cases of HDH of non-varicose origin were diagnosed out of a total of 225 cases of HDH consulting the emergency department, with a prevalence of 40.44%.
The mean age of our patients was 54.8 years (20-84 years), with a male predominance of 70.3% and a sex ratio of M/F : 2.3.
11 patients (12.08%) had a history of smoking, 11 (12.08%) had heart disease on anticoagulants, 10 (11%) had taken NSAIDs, 8 (8.79%) had nephropathy at the hemodialysis stage, and 7 (8%) were hypertensive.
The mode of externalization of HDH was melena associated with hematemesis in 26 patients (28.6%), isolated melena in 44 (48.4%), hematemesis in 16 (17.6%) and rectal discharge in 5 (5.5%).
The main etiologies of HDH of non-varicose origin revealed by FOGD were: gastro-duodenal ulcer in 73 patients (80.2%), with Forrest Ib ulcer in 9 (12.3%), Forrest IIa in 4(5.4%), Forrest IIb in 4(5.4%), Forrest IIc in 13(17.8%) and Forrest III in 43(59%).
Of the 91 patients, 15(16.48%) had esophagitis, 5(5.5%) had gastric process, 1(1.09%) had duodenal process and 8 patients (8.8%) had angiodysplasia lesions.
All patients were treated with a loading dose of injectable PPI, followed by a maintenance dose.
Endoscopic haemostasis was required in 19 patients (20.8%), of whom 8 (8.7%) benefited from injection of adrenaline serum and placement of haemostatic clips, 2 patients (2.2%) from exclusive injection of adrenaline serum, 8 patients (8.7%) from exclusive placement of haemostatic clips and one patient (1.09%) benefited from per-endoscopic surgical suturing.
The mortality rate in our study was 3.2%.

Conclusion

HDH of non-varicose origin remains dominated by ulcerative origin. Impregnation with PPIs prior to FOGD and the possibility of endoscopic haemostasis reduce the mortality rate.