Introduction

The optimal timing of endoscopy in acute upper gastrointestinal bleeding (AUGIB) management remains debated. We assessed time to endoscopy's impact on rebleeding and mortality based on patient characteristics and pre-endoscopic factors.

Aims & Methods

Data from 3,001 patients with AUGIB undergoing endoscopy within 48 hrs of referral from the prospective multicentre UK 2022 audit were analysed. Patients were categorised into 0-12 hrs, 12-24 hrs, and 24-48 hrs groups based on the time to endoscopy from referral. Regression analyses, adjusting for age, admission status (inpatient vs new admission), vital signs, symptoms, comorbidities, laboratory parameters, red blood cell transfusion, and pre-endoscopic management, assessed the association between endoscopy timing and rebleeding and mortality.

Results

Patients undergoing endoscopy within 0-12 hrs were younger, more likely to be haemodynamically unstable, and had a higher median Glasgow Blatchford Score (GBS) compared to those undergoing endoscopy in the 12-24 and 24-48 hrs groups. Despite a higher proportion receiving endotherapy (41% for the 0-12 hrs group, 28% for the 12-24 hrs group, and 17% for the 24-48 hrs group; p<0.001), the 0-12 hrs group had the highest rates of rebleeding (16%) and mortality (10%), compared to 9% rebleeding and 6% mortality in the 12-24 hrs group, and 7% rebleeding and 5% mortality in the 24-48 hrs group (p<0.001). The median length of stay was longer for the 0-12 hrs and the 24-48 hrs groups at 5 days, compared to 4 days in the 12-24 hrs group (p < 0.001). (see table)

Regression analysis indicated that, compared to the 12–24-hrs group, the 0–12 hrs group had higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69, p < 0.001), after adjusting for confounding variables. However, the 24–48 hrs group exhibited comparable odds of rebleeding (OR 0.93, 95% CI 0.60-1.45, p < 0.001) compared to the 12–24-hrs group. Regression analysis for mortality showed the 0-12 hrs group had higher odds of mortality compared to the 12-24 hrs group (OR 1.59, 95% CI 1.09-2.34, p = 0.001), while the 24-48 hrs group had similar odds of death (OR 0.74, 95% CI 0.43-1.23, p = 0.001).

Conclusion

The findings suggest a complex relationship between the timing of endoscopy and clinical outcomes in patients with AUGIB. Earlier endoscopy (0-12 hrs) may be associated with a higher risk of rebleeding, mortality and resource utilisation, while later endoscopy (24-48 hrs) may not be associated with increased adverse outcomes, but may lead to a longer hospital stay. Despite the initial severity of illness, early endoscopy may not translate to improved patient outcomes in AUGIB management. These results highlight the need for individualised management when determining the optimal timing of endoscopy in AUGIB.

Introduction

In Japan, more than ten years have passed since direct oral anticoagulants (DOACs) was released in 2011. The differences between DOACs and warfarin (VKA) have gradually become clearer, and many studies have been reported regarding the differences in gastrointestinal bleeding risk ^(1)(2)(3). However, there are few reports that examine the prevalence of gastric mucosal injury or ulcers rather than the risk of bleeding.

Aims & Methods

The aim of this study is to reveal the clinical features about patients with gastric ulcer taking anticoagulants (DOACs or VKA). This study is a retrospective cross-sectional study conducted in a single hospital. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2015 and December 2022. We focused on subjects who took anticoagulants (DOACs or VKA), and compared the prevalence of gastric ulcer between subjects taking DOAC and those taking VKA. Subjects taking anticoagulants were limited to those taking that anticoagulant as the only anti-thrombotic agents. This study was conducted separately for subjects taking antacids (P-CAB or PPI) and those not taking antacids (NO P-CAB, NO PPI and NO H2RA). Statistical analyses were performed by Fisher’s exact test.

Results

Of the 8,602 subjects analyzed, 522 subjects were taking anticoagulants, of which 103 were taking VKA (76 men, 27 women, mean age 73.1±12.0 years) and 297 were taking DOACs (205 men, 92 women, mean age 74.9±8.7 years). Among subjects taking DOACs, 33 subjects received Dabigatran, 93 received Edoxaban, 87 received Rivaroxaban, and 84 received Apixaban. The prevalence of gastric ulcer in subjects taking antacids was 6.7% (4/60) on VKA and 2.9% (5/170) on DOACs (p=0.24). The prevalence of gastric ulcer in subjects not taking antacids was 23.1% (9/39) on VKA and 5.4% (6/111) on DOACs (p=0.004).

Conclusion

Without concomitant use of antacids, subjects taking DOACs had a statistically significantly lower prevalence of gastric ulcers than those taking warfarin. These results suggest that DOACs are gentler on the gastric mucosa and user friendly than warfarin.

References

(1) Miller CS, et al. Clin Gastroenterol Hepatol. 15(11): 1674-1683, 2017
(2) Ray WA, et al. JAMA. 320(21): 2221-2230, 2018
(3) Ingason AB, et al. Ann Intern Med. 174(11): 1493-1502, 2021

Introduction

Cirrhosis is a chronic condition with a high mortality. Cirrhotic patients with portal hypertension frequently present with large esophageal varices with bleeding or need for endoscopic intervention. The choice of treatment for variceal hemorrhage is endoscopic ligation and beta-blockers, which can be used as secondary prophylaxis. The pleiotropic effects of statins have been reported for the treatment of cardiovascular diseases, but at the liver level they favor the reduction of the hepatic venous pressure gradient (HVPG), with a decrease in the number of variceal hemorrhage events; however, their use had been restricted in cirrhotic patients due to their association with elevations in liver biochemistries.

Aims & Methods

To evaluate the safety statins in cirrhotic patients with an indication for high cardiovascular risk. And as a secondary aim, determine the presence of variceal hemorrhage during follow-up. This retrospective cohort study was carried out by the "Centro Médico Nacional 20 de Noviembre" between 2018 to 2022. Child Pugh A and B cirrhotic patients with a history of variceal hemorrhage or large varices with endoscopic ligation intervention without active hemorrhage were included and observed over a period of 4 years. To determine adverse events, compatible clinical data and biochemical examinations were searched in the electronic record, and pharmacovigilance committee records were reviewed.

Results

A total of 106 patients were included, of which 53 with statin use and 53 without statins. The characteristics were 41.5% men (n=44), 58.5% women (n=62). The average age was 62 ± 10 years. In order of frequency, the causes were: cryptogenic 25.5% (n=27), hepatitis C virus (HCV) 21.7% (n=23), primary biliary cholangitis (PBC) 14.2% (n=15), metabolic dysfunction-associated fatty liver disease (MAFLD) 13.2% (n=14), alcohol 12.3% (n=13), autoimmune hepatitis (AIH) 11.3% (n=12), hepatitis B virus (HBV) 1.9% (n= 2). With Child Pugh A 67% (n=71) Child Pugh B 35% (n=33). In the statin and non-statin group, the average values of the following variables were PT 12.7 ±1.9 vs 14 ±2.2, AST 39.6 ±24 vs 61 ±40, ALT 37.6 ±28 vs 51 ±38, albumin 3.8 ±0.6 vs 3.6 ±0.5, total cholesterol 157.6 ±35 vs 179.4 ±68, INR 1.06 ±0.17 vs 1.1 ±0.18 (p=< 0.05) (Table 1). In the group of patients with statin use in 18.4% (n=10) Variceal ligation was performed, and in the group without statins, 24.5% (n=13), with a RR of 1.075, 95% CI (0.8-1.3). In the group of patients with statin use, 9.5% (n=5) had a bleeding event, and in the group without statins, 7.5% (n=4) had a bleeding event, with an RR of 1.25, CI 95% (0.3-4.4). None of the participants had clinical adverse effects.

Table 1. Demographics, selected clinical characteristics, and outcomes of patients

Conclusion

The use of statins in cirrhosis compensated with portal hypertension was safe. In this study we could not demonstrate the pleiotropic effect of statins, probably due to the sample size. Therefore, it is necessary to generate subsequent studies including a larger number of patients.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

Difficult pancreatic duct stones, including large and/or impacted pancreatic duct stones, cannot usually be treated by conventional endoscopic retrograde cholangiopancreatography (ERCP). Extracorporeal shock wave lithotripsy (ESWL) and surgery including Frey operation are the main treatment for such difficult pancreatic duct stones. Recently, cholangiopancreatoscopy-assisted lithotripsy using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) provides an alternative modality for ductal clearance.

Aims & Methods

We aimed to evaluate the clinical outcomes of cholangiopancreatoscopy-assisted lithotripsy and Frey surgery in patients with difficult pancreatic duct stones.
From January, 2018 to December, 2023, a total of 12 (10 male and 2 female) consecutive patients, 51 (38-71) years old, with large and/or impacted pancreatic duct stones undergoing single-operator cholangiopancreatoscopy-assisted lithotripsy using EHL and/or LL, and 14 (10 male and 2 female) consecutive patients, 48 (33-62) years old, undergoing Frey surgery in a medical center were retrospectively analyzed. Clinical outcomes including stone size, lithotripsy and surgery procedures, ductal clearance, complications, and length of hospital stay were evaluated.

Results

In the group of cholangiopancreatoscopy-assisted lithotripsy, 11 (91.7%; 11/12) patients were successfully treated in 19 (median 2; range 1-3) sessions including LL (n=16) and EHL (n=3) to achieve ductal clearance (Clinical success). The technical success rate was 94.7% (18/19). Six (50%; 6/12) patients with pancreatic duct stones were successfully treated at the first session of cholangiopancreatoscopy-assisted lithotripsy. After the procedure, mild pancreatitis occurred in 5 (26.3%; 5/19) patients. The median length of hospital stay was 4 (2-9) days. In the group of Frey surgery, 11 (78.6%; 11/14) patients underwent the surgery successfully. Adverse events after Frey surgery occurred in 3 (21.3%; 3/11) patients, including intra-abdominal abscess, peritonitis and bacteremia, respectively. The median length of hospital stay was 16 (7-58) days.

Conclusion

Cholangiopancreatoscopy-assisted lithotripsy is an effective and safe modality for difficult pancreatic duct stones. Comparing with Frey surgery, cholangiopancreatoscopy-assisted lithotripsy can be an initial therapy.

Disclosure

The authors declare no conflicts of interest.

Introduction

Terminal ileitis is the endoscopic manifestation of a wide range of diseases: inflammatory, infectious, vasculitic, ischemic, drug-induced and malignancy. When it comes to asymptomatic terminal ileitis, it is incidentally found on screening ileo-colonoscopy. The prevalence of this entity was not well established and is found in few studies with heterogenous results.

Aims & Methods

We conducted this study to define the prevalence and histopathologic characteristics of asymptomatic terminal ileitis. This is a cross-sectional study. The study population is composed of all the patients that underwent a colonoscopy between September 2020 and March 2023. Selection bias were avoided by excluding patients with inflammatory bowel disease (IBD), sacroiliitis, chronic diarrhea, elevated calprotectin, medical history of ileitis diagnosed either on previous colonoscopy or on imaging showing wall thickening, and those with altered anatomy (colectomy with ileo-colic anastomosis).

Results

A total of 3901 colonoscopies were realized in a single center between September 2020 and March 2023; 3035 met our inclusion criteria based on medical history and the indication of the colonoscopy that excluded the above-mentioned reasons. Ileal intubation was performed in 91.4% (n=2773) of these cases, representing the final study population. Terminal ileitis was found in 5% (n=139) of patients, of whom 58.3% (n=81) were men and 41.7% (n=58) were women. The median age at diagnosis was 50 and and the mean age was 49.43 +/-15.5. The three main indications for colonoscopy were: colorectal cancer screening in 57.5% (n=80) of cases, gastrointestinal red flag symptoms including bleeding, anemia, and weight loss in 28.8% (n=40) of cases, and abdominal pain in 13.7% (n=19) of cases. Biopsies were performed in 90.6% (n=126) of ileo-colonoscopies and showed, regardless of the indication, normal histology, erosive and ulcerated ileitis, and non specific and other findings in 12.7% (n=16), 36.5% (n=46) and 44.4% (n=56) of samples respectively. Definitive Crohn’s disease diagnosis was found in 5.75% (n=8) of asymptomatic ileitis patients.

Conclusion

The prevalence of asymptomatic terminal ileitis was 5% in our population. This finding was not associated with the indication of the colonoscopy, namely colorectal cancer screening, gastrointestinal red flag symptoms including bleeding, anemia, and weight loss and abdominal pain. The clinical significance of this finding requires longitudinal follow-up studies to assess the incidence of IBD or other conditions.