Introduction

Gastrointestinal bleeding (GIB) and Ischemic heart disease (IHD) both remain the important causes of morbidity and mortality. Patients with IHD are more likely to suffer from GIB due to the characteristics of the population, heart disease, stress state and long-term use of antithrombotic drugs^[1-3]. Previous studies have found that patients with simultaneous GIB and IHD have higher mortality than that of each individual disease^[4-5]. Treatment for those patients is a challenge for both the cardiologists and gastroenterologists. In order to assess the frequency of in-hospital mortality in patients with GIB and IHD, and determine the potential risk factors for this condition, we designed and conducted this single center study.

Aims & Methods

Our study assessed the hospitalized outcomes of patients with simultaneous GIB and IHD. Moreover, we explored the risk factors of in-hospital mortality in those patients.We performed a retrospective study in West China hospital between January 2014 and December 2018. Patients diagnosed with GIB and IHD were included. The primary outcome was in-hospital mortality for all causes. Clinical and laboratory data were collected and analyzed for clinical characteristics and potential risk factors of in-hospital mortality.

Results

574 GIB patients with IHD were enrolled in the current study, and among them 107 in-hospital deaths were observed (in-hospital mortality rate of 18.64%). The causes of death included cardiovascular death (46, 42.99%), hemorrhagic shock (10, 9.35%), severe infection (33, 30.84%), and other causes (18, 16.82%). Patients who died were older than survivors [78（68, 82） vs. 74（65, 80），P = 0.008], with a higher incidence of COPD (27.10% vs. 13.70%, P=0.001) and chronic renal failure (47.66% vs. 27.19%, P<0.001). Patients with a higher heart rate at admission (90 vs. 81, P=0.006), or with a course of CHD less than 3 months (53.27% vs. 32.76%, P<0.001) were more likely to die. More patients in death group received plasma infusion (24.30% vs. 7.92%, P<0.001), and present with acute coronary syndrome (53.27% vs. 38.97%, P=0.007). Compared with survivors, patients who died showed increased peak white blood cell (WBC) count [18.75(14.35, 24.9) vs. 9.79 (7.19, 13.82) ×109/L,P < 0.001], increased peak INR [1.51 (1.21, 2.58) vs. 1.13 (1.05, 1.31),P < 0.001)], and lower minimum platelet counts [94 (52, 147) vs. 128 (83, 180)×109/L, p<0.001]. In multivariable logistic analysis, age [OR (95% CI) =1.032 (1.006-1.058), P=0.014], peak WBC count [OR (95% CI) =1.123 (1.085-1.163), P<0.001], peak INR levels [OR (95%CI) =1.220(1.061-1.402), P=0.005], and heart rate at admission [OR (95%CI) =1.015(1.002-1.028), P=0.026] were independent predictors of in-hospital mortality.

Conclusion

Patients with simultaneous GIB and IHD had a high in-hospital mortality. Age, peak WBC count, peak INR levels, and heart rate at admission were independent risk factors for in-hospital death.

References

[1]. Steg PG, Huber K, Andreotti F, Arnesen H, Atar D, Badimon L, Bassand JP, De Caterina R, Eikelboom JA, Gulba D, Hamon M, Helft G, Fox KA, Kristensen SD, Rao SV, Verheugt FW, Widimsky P, Zeymer U, Collet JP. Bleeding in acute coronary syndromes and percutaneous coronary interventions: position paper by the Working Group on Thrombosis of the European Society of Cardiology. Eur Heart J. 2011 Aug;32(15):1854-64.
[2]. Cea Soriano L, Lanas A, Soriano-Gabarró M, García Rodríguez LA. Incidence of Upper and Lower Gastrointestinal Bleeding in New Users of Low-Dose Aspirin. Clin Gastroenterol Hepatol. 2019 Apr;17(5):887-895.e6.
[3]. Kawasaki K, Kurahara K, Yanai S, Kochi S, Fuchigami T, Matsumoto T. Low-Dose Aspirin and Non-steroidal Anti-inflammatory Drugs Increase the Risk of Bleeding in Patients with Gastroduodenal Ulcer. Dig Dis Sci. 2015 Apr;60(4):1010-5. ​
[4]. Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY trial. J Am Coll Cardiol 2007;49:1362-8
[5]. Rao SV, O'Grady K, Pieper KS, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol 2005;96:1200-6.

Introduction

Antithrombotic drugs (AT) pose an increased risk of upper gastrointestinal bleeding (UGIB), and their discontinuation carries the risk of thromboembolic events, presenting a challenge for clinicians (1,2). Clinical practice guidelines advocate for a restrictive approach, recommending non-discontinuation and/or early reintroduction based on the drug and its indication (3).
Despite available literature, controversy persists regarding the outcomes of patients with UGIB on antithrombotic therapy, both in the short and long term, as well as the potential impact of drug discontinuation (4,5).

Aims & Methods

Aim:
To determine the impact of ATs on in-hospital and delayed outcomes. Also, to determine whether suspension and resumption influenced delayed outcomes.
Methods:
Prospective registry analysis of UGIB patients between 2013-2021. Anticoagulants and antiplatelets were classified as AT drugs. Outcomes examined included in-hospital mortality and delayed-6 months cardiovascular, bleeding and mortality events.

Results

1345 patients were included, with 21.7% on anticoagulants and 19.1% on antiplatelets.
Patients on ATs were older (73 vs. 59 years; p<0.0001) and had a higher rate of comorbidities, has longer delay of endoscopic performance (11±11h vs. 9.6±8h; p=0.027), with gastric erosions being more usual (14.2% vs.9.1%; p=0.006). Table shows main outcomes.

	Non-AT (n=839)	AT (n=506)	P	Aspirin (n=195)	Thienopyridine (n=29)	Double antiaggregating (n=24)	VKA (n=179)	NACO (n=49)
Endoscopy therapy	48.3%	38.5%	0.001	75 (38.5%)	12 (41.4%)	7 (29.2%)	62 (34.6%)	20 (40.8%)
Rescue therapy	6.1%	3.8%	0.083	8 (4.1%)	17 (58.6%)	0	4 (2.2%)	1 (2%)
Rebleeding	10.5%	9.7%	0.702	20 (10.3%)	1 (3.4%)	18 (75%)	12 (6.7%)	4 (8.2%)
Transfusion	56.3%	66.2%	0.000	127 (65.1%)	17 (58.6%)	0	115 (64.2%)	41 (83.7%)
In-hospital mortality	12%	8%	0.028	14 (7.2%)	0	1 (4.2%)	13 (7.3%)	1 (2%)
Delayed cardiovascular event	3.4%	13.7%	0.000	18 (9.2%)	5 (17.2%)	1 (4.2%)	31 (17.3%)	12 (24.5%)
Delayed hemorrhagic event	12.9%	22.9%	0.000	43 (22.1%)	5 (17.2%)	6 (25%)	41 (22.9%)	12 (24.5%)
Delayed mortality	6%	9.4%	0.034	17 (8.7%)	2 (6.9%)	2 (8.3%)	19 (10.6%)	4 (8.2%)

AT suspension <72h was associated with increased in-hospital mortality (14.9% vs. 2.3%; p=0.001), especially <24h (20.9% vs. 2.6%; p<0.0001).
Delayed mortality was higher in patients on ATs who suspended them more than 7 days (17% vs.8.7%; p= 0.033), with no differences when last <72h. Suspension/reintroduction have no effect on other delayed outcomes.
Multivariate analysis identified ASA≥3 (HR 12.20;95%CI 3.69-56-92; p<0.001), disseminated malignancy (HR 4.73; 95%CI 1.92-11.42; p=0.001) and rebleeding (HR 19.25; 95%CI 9.07-43.04) as independent risk factors for in-hospital mortality, with AT therapy (HR 0.27; 95%CI 0.13-0.55; p<0.001), NSAIDS (HR 0.26; 95%CI 0.07-0.75; p=0.023), endoscopic therapy (HR 0.49; 95%CI 0.24-0.96; p=0.040) and hemoglobin levels being protectives factors HR 0.80; 95%CI 0.69.0.93; p=0.004).
Logistic regression analysis for delayed mortality showed that age (HR 1.04; 95%CI 1.02-1.07; p=0.001), disseminated malignancy (HR 3.49; 95%CI 1.81-7.86; p=0.004), esophageal varices HR 3.34; 95%CI 1.62-6-64; p=0.001), ischemic heart disease (HR 2.44; 95%CI 1.10-5.19; p=0.023) and a being an inpatient (HR 1.92; 95%CI 1.00-3.98; p=0.042) were independent risk factors for the outcome.

Conclusion

Despite increased comorbidities and older age, patients with AUGIB on ATs had lower in-hospital mortality, with no differences in other relevant outcomes. In fact, our results suggest that AT treatment provides a survival benefit, possibly related to a higher risk of bleeding in milder lesions.
Regarding delayed mortality, it was higher in patients on AT, determined by the comorbidity leading to their prescription.
Interestingly, early resumption of AT was associated with higher in-hospital mortality, while reintroduction after 7 days increased delayed one.

References

1. Lanas A, Carrera-Lasfuentes P, Arguedas Y, et al. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Clin Gastroenterol Hepatol 2015;13:906-12 e2.
2. Chan FK, Leung Ki EL, Wong GL, et al. Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal Hemorrhage. Gastroenterology 2016;151:271-7.
3. Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021;53:300-332.
4. Dunne PDJ, Laursen SB, Laine L, et al. Previous Use of Antithrombotic Agents Reduces Mortality and Length of Hospital Stay in Patients With High-risk Upper Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2019;17:440-447 e2.
5. Marmo R, Occhipinti V, Zullo A, et al. Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study. J Clin Gastroenterol 2023;57:278-284.

Introduction

Upper gastrointestinal bleeding(UGIB), both variceal(VB) and nonvariceal(NVB), is a prevalent cause of hospitalization, readmission, and poor outcomes among patients with cirrhosis. However, studies typically focus on VB given its association with higher morbidity and mortality rates(1) although some other studies comparing VB and NVB among patients with cirrhosis reported no difference in outcomes(2). On the other hand, literature is controversial about NVB outcomes between cirrhosis and non-cirrhosis(3,4). Despite this, the existing literature of NVB in cirrhosis is less robust (few prospective studies with no differentiation between compensated and decompensated cirrhosis).

Aims & Methods

Aim: To compare outcomes between VB and NVB among patients with cirrhosis and between NVB patients with (compensated and decompensated) and without cirrhosis. Therefore, we sought to explore predictors of mortality in NVB patients.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’(2013-2020).
VB was defined as esophageal or gastric varices as source of bleeding. NVB was defined as all other etiology(including portal-hypertensive gastropathy)
Patients with a Child-Pugh A and B(score 5-9) have compensated cirrhosis and those with class C cirrhosis(score 10-15) have decompensated cirrhosis.
The primary outcome of our study was in hospital and delayed mortality. Secondary outcomes included intervention, length of hospital stay, rebleeding and delayed UGIB.
Statistical analysis was performed by SPSS. Categorical variables were compared using χ2 test. Continuous variables using Student’s t-test or Mann-Whitney U-test. Multivariate logistic regression analysis was performed to identify independent risk factors for mortality.

Results

We included 1345 UGIB patients, 319 had cirrhosis, 190 VB (59.6%) and 129 NVB (40.4%). There were no differences in relevant outcomes between VB y NVB in cirrhosis except for need of endoscopy therapy (74.2% vs.41.4%, p<0.001)
In the whole cohort, 1139 where NVB: 1011 non-cirrhotic (88.8%), 129 cirrhotic (11.2%): 81 compensated and 21 decompensated (26 without information).
Main outcomes between non-cirrhotic and compensated/decompensated cirrhotic with NVB are shown in the table.

Outcomes	Non-cirrhotic	Compensated	Descompensated	p
Reebleding	9%	7.4%	23.8%	0.047 (for descompensated)
Nº RBC	2.6	2.88	5.33	0.034 (for descompensated)
Endoscopy therapy	39.1%	37.5%	52.4%	n.s (0.443)
Surgery	4.8%	1.2%	0%	n.s (0.203)
Interventional radiology	1.1%	1.2%	0%	n.s (0.883)
Lenght hospital stay	8.59	8.55	12.33	0.022 (for descompensated)
In-hospital mortality	7.2%	13%	45%	<0.001 (for descompensated)
Delayed-6months UGIB	6.1%	10.8%	11.1%	n.s. (0.210)
Delayed-6months mortality	8.8%	18.5%	14.3%	0.013 (for compensated)

Independent risk factors for in-hospital mortality were age (HR 1.08,95%CI 1.01-1.61,p=0.049), misbalance of chronic condition (HR 11.33,95%CI 2.26-56.71,p=0.003) and Child-Pugh score (HR 1.88,95%CI 1.18-2.99,p=0.008).

Conclusion

In our study we show that, at the end, prognosis depends on basal status, namely being compensated or decompensated, and is not only about have or not to have cirrhosis or about VB or NVB. Patients with decompensated cirrhosis have worse outcomes in terms of higher rates of rebleeding, number of packet blood cell transfused, length of hospital stay and in-hospital mortality. After performed multivariate analysis, Child-Pugh score remains as an independent risk factor for mortality, indicating that liver function deterioration marks the evolution.

References

1. Farooq U, Tarar ZI, Franco D, Kamal F, Abegunde AT. Comparison of outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis: Insights from a Nationwide Inpatient Sample. Ann Gastroenterol. 2022 Nov-Dec;35(6):618-626.
2. Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology. 2018 Apr;67(4):1458-1471.
3. Rudler M, Rousseau G, Benosman H, Massard J, Deforges L, Lebray P, Poynard T, Thabut D. Peptic ulcer bleeding in patients with or without cirrhosis: different diseases but the same prognosis? Aliment Pharmacol Ther. 2012 Jul;36(2):166-72.
4. Lecleire S, Di Fiore F, Merle V, Hervé S, Duhamel C, Rudelli A, Nousbaum JB, Amouretti M, Dupas JL, Gouerou H, Czernichow P, Lerebours E. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol. 2005 Apr;39(4):321-7.

Introduction

Direct oral anticoagulants (DOACs), particularly rivaroxaban and apixaban, are increasingly utilized to manage thromboembolic conditions due to their favorable efficacy and safety profiles. However, gastrointestinal bleeding (GIB) remains a significant concern associated with these medications, particularly considering pharmacogenetic variations among populations. This study aims to evaluate the frequency and identify risk factors associated with GIB in patients using rivaroxaban and apixaban in a Mexican healthcare setting.

Aims & Methods

This retrospective observational study analyzed data from January 2018 to December 2023 at the Centro Médico Nacional 20 de Noviembre, Mexico City. The cohort consisted of 278 patients: 136 on DOAC therapy (rivaroxaban or apixaban) and 142 controls without anticoagulation. Clinical data, demographic characteristics, comorbidities, and concomitant medications were systematically reviewed. Statistical methods employed included chi-square tests, Student's t-tests, and logistic regression analysis to assess the risk factors and association between anticoagulant type and incidence of GIB.

Results

The study population had a mean age of 67.36 ± 15.05 years, with an equal gender distribution (52.9% male). Rivaroxaban was significantly linked to increased GIB-related hospitalizations compared to controls (OR 1.29, 95% CI: 1.10–1.52, p < 0.001), while apixaban showed no statistically significant increase. NSAID co-administration dramatically raised the risk of GIB in rivaroxaban users (OR 16.1, 95% CI: 1.22–212.6, p = 0.03). Patients treated with DOACs experienced more hospitalizations (average 0.49 ± 0.80) and longer hospital stays (2.19 ± 3.54 days) compared to controls (0.30 ± 0.62 hospitalizations, 0.99 ± 2.68 days, respectively). Mortality rates were not significantly different between groups.

Conclusion

Rivaroxaban and apixaban present similar overall risks of gastrointestinal bleeding, although rivaroxaban is associated with higher hospitalization rates. Concomitant NSAID use substantially elevates the risk in patients on rivaroxaban. This underscores the necessity of individualized anticoagulant management strategies, especially in populations with distinct genetic and clinical characteristics, such as the Mexican demographic.

References

1. Lopes RD, Guimarães PO, Kolls BJ, et al. Gastrointestinal bleeding with novel oral anticoagulants: A systematic review and meta-analysis. BMJ. 2015;350:h1857.
2. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.
3. Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981-992.

Introduction

Upper gastrointestinal bleeding (UGIB) is one of the main potentially life-threatening emergencies encountered in gastroenterology that requires prompt management. For this reason, numerous prognostic scores have been developed to predict the level of risk in patients. However, there are few studies in the literature comparing these scores.

Aims & Methods

The main objective of this study was to compare the performance of the pre-endoscopic scores Glasgow-Blatchford Score (GBS), Rockall Score (pRS), and quick Sequential Organ Failure Assessment (qSOFA) in predicting the severity of UGIB according to predefined criteria.
Methods: This is a retrospective descriptive and analytical study of 102 patients who presented with upper gastrointestinal bleeding at the International University Hospital Cheikh Khalifa over a period of 1 year between October 2021 and October 2022. Scores were calculated for each patient with complete medical records. The data was analyzed using the Jamovi 2.2.5 software. The accuracy of each risk score in predicting clinical criteria was evaluated by the area under the receiver operating characteristic curve (AUROC). A p-value less than 0.05 was considered statistically significant.

Results

The included patients had a mean age of 57.1 years with a slight female predominance (53.9%). GBS was found to be more predictive of the risk of admission to the Intensive care Unit (ICU) and the need for blood transfusion than pRS and qSOFA with an AUROC of 0.914 for these two criteria. GBS was also more predictive of the risk of therapeutic intervention (AUROC 0.882) compared to pRS (AUROC 0.788) and qSOFA (AUROC 0.676). Regarding endoscopic intervention, pRS and GBS were equally able to predict this criterion with moderate power (AUROC pRS 0.721) (AUROC GBS 0.747). qSOFA showed no significant performance, especially in its preferred domain of admission to the ICU (AUROC 0.735) (Table). None of the 3 scores was able to predict the need for surgical intervention.

Table: Comparison of AUC, sensitivity, specificity, PPV and NPV along with cut-off value of Glasgow-Blatchford Score, pre-Rockall, and Quick-Sofa scores to predict the clinical outcomes

Conclusion

At the end of this study, the use of GBS and pRS in daily clinical practice in emergency departments is strongly recommended to predict the need for therapeutic intervention, hospitalization, or re-bleeding episodes. However, it would be interesting to study the usefulness of these prognostic scores, especially qSOFA, through larger prospective studies.

References

1. Cúrdia Gonçalves T, Barbosa M, Xavier S, et al. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE Port J Gastroenterol. nov 2018;25(6):299‑307.
2. Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol. déc 2019;13(12):1161‑7.
3. Aquarius M, Smeets FGM, Konijn HW, et al. Prospective multicenter validation of the Glasgow Blatchford bleeding score in the management of patients with upper gastrointestinal hemorrhage presenting at an emergency department. Eur J Gastroenterol Hepatol. sept 2015;27(9):1011‑6.
4. Li Y, Lu Q, Song M, Wu K, Ou X. Comparisons of six endoscopy independent scoring systems for the prediction of clinical outcomes for elderly and younger patients with upper gastrointestinal bleeding. BMC Gastroenterol. 13 avr 2022;22(1):187
5. Renukaprasad AK, Narayanaswamy S, R V. A Comparative Analysis of Risk Scoring Systems in Predicting Clinical Outcomes in Upper Gastrointestinal Bleed. Cureus. juill 2022;14(7):e26669
6. Taslidere B, Sonmez E, Özcan AB, Mehmetaj L, Keskin EB, Gulen B. Comparison of the quick SOFA score with Glasgow-Blatchford and Rockall scores in predicting severity in patients with upper gastrointestinal bleeding. Am J Emerg Med. juill 2021;45:29‑36

Disclosure

All co-authors have seen and agree with the contents of the manuscript and there is no conflict of interest.

Introduction

Contemporary data on the outcomes of upper gastrointestinal bleeding (UGIB) in patients with chronic kidney disease (CKD) is lacking.

Aims & Methods

Using international classification of diseases, 10th revision codes, all hospitalisations for UGIB were extracted from the National Inpatient Sample. Admissions were stratified by the presence of CKD. Subanalysis was performed by type of bleeding.

Results

Of the 918,925 UGIB admissions analysed, 239,985 (26.1%) had a medical history of CKD. CKD patients were more likely to be male and less likely to be white compared to patients without CKD. CKD patients had higher crude rates of endoscopy but lower likelihood of undergoing surgery and interventional radiology to control blood loss. On adjusted analysis compared to patients with no CKD, CKD patients had higher odds of all-cause in-hospital mortality (adjusted odds ratio (aOR) 1.34 95% confidence interval (CI) 1.29-1.39). When stratified by bleed type, CKD patients had higher adjusted odds of mortality for both variceal and non-variceal bleeds, compared to patients without CKD.

Conclusion

Patients with CKD admitted with UGIB are more comorbid and are more likely to suffer in-hospital mortality compared to patients without CKD. These differences persisted on-sub-analysis for type of bleed. Knowledge of these trends is important for managing this prevalent patient group.