Introduction

In the treatment of bleeding from GI vascular malformations, the priority of endoscopic hemostasis methods, particularly argon plasma coagulation (APC), is unquestionable. Until now, no effective medication-based therapy has been available as an alternative or supplemental method. Previous studies have reported on the ineffectiveness of steroids, estrogens, and progestogens. In the past decade, several promising clinical trials have been conducted regarding the use of thalidomide and long-acting-release (LAR) octreotide to reduce bleeding from vascular malformations.

Aims & Methods

At the Department of Internal Medicine-Gastroenterology of the Petz Aladár University Teaching Hospital in Győr-Moson-Sopron County, in patients who did not respond to endoscopic treatment, either.
1. Investigate the efficacy and side effects of thalidomide,
2. Investigate the efficacy and side effects of LAR octreotide in patients resistant to thalidomide treatment.

From July 2021 to February 2024, 25 patients were treated for bleeding and anemia from GI vascular malformations. In 20 patients, bleeding was stopped with 35 (1-2) APC treatments. 5 polymorbid patients (male:female= 1:4, average age ~64.6 years) required regular transfusions despite previous ~7.2 APC treatments. Their predominant underlying diseases included Banti's syndrome, autoimmune hemolytic anemia, ischemic cardiomyopathy, atrial fibrillation, Osler's disease, and autoimmune hepatitis. These 5 patients underwent a 3-month course of 100mg thalidomide per day. In patients where thalidomide was ineffective or caused side effects, LAR octreotide intramuscular injections were indicated once every four weeks at a 30mg dose. Visits, blood counts, and lab tests were conducted monthly.

Results

With thalidomide treatment, the transfusion requirement ceased in 2/5 patients. In 2/5 patients, the treatment was suspended due to ineffectiveness and side effects (deep vein thrombosis, emesis). Treatment was ineffective in 1/5 patients. In the last 3 patients, LAR octreotide treatment was also ineffective. Mild side effects (meteorism, nausea, exanthemas) were observed in these patients.

Conclusion

In the care of patients bleeding from vascular malformations resistant to endoscopic therapy,
1. Thalidomide may be an effective medication,
2. Close patient monitoring is important to filter out side effects,
3. The effectiveness of LAR octreotide cannot be determined based on the study,
4. Further follow-up studies are necessary.

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

Acute GI bleeding (GIB) can present significant mortality. Topical Endoscopic Haemostatic Agents (TEHAs) have been added to endoscopic treatment modalities for GIB’s. There is no dedicated international consensus on the role of TEHAs in GIB control. We aimed to develop the first expert led consensus statements to provide international guidance on the use of TEHAs in acute GIB’s.

Aims & Methods

A team of 15 world renowned experts in the field of acute GIB from 8 countries were recruited. All panel members have published extensively and possess significant expertise in the cognitive and endoscopic aspects of GIB management. A first meeting was held to define statements and divide them in 5 subgroups: Indications of therapy, mechanism of action, usage, safety and published evidence. Using the RAND/UCLA appropriateness method, they voted on statements by combining expert collective judgement and best available evidence in a two-round voting process. Extensive literature searches were carried out on each statement to provide the latest evidence base to support decisions. A second meeting was held to discuss the results of the first meeting and refine statements. A second round of voting was conducted to rate refined statements. Statements were rated on a 9-point interval scale (1 to 9). A higher score implied a “more appropriate” statement i.e. an important statement in the management of GIB patients. Four statistical methods were used to delineate statements that satisfied all criteria of appropriateness: 1. mean absolute deviation from the mean, 2. BIOMED concerted action on appropriateness definition, 3. RAND method and 4. inter-percentile range adjusted for symmetry methods. For a statement to be considered appropriate it had to meet all statistical definitions of appropriateness showing consensus agreement.

Results

24 statements were presented in round one. 15 statements met all four statistical definitions of appropriateness and proceeded to round two. Following round two, a list of 11 final consensus statements were scored as appropriate and met all four statistical definitions of appropriateness showing overall consensus being reached (Table 1). There was 100% agreement that TEHAs are effective in achieving haemostasis in malignancy related GIB’s (statement 2), can be used as ‘salvage’ therapy for non-variceal GIB’s (statement 4), and can be used as a bridge to definitive non-endoscopic therapy for persistent GIB’s (statement 5). These represent the most important indications for TEHAs that endoscopists should recognise.

Table 1: Final eleven statements voted as appropriate reaching expert consensus after round two. (Score 1-3 = inappropriate statement, score 4 – 6 = uncertain about statement, score 7 – 9 = appropriate statement), TEHAs = Topical Endoscopic Haemostatic Agents

Conclusion

We present the first dedicated international consensus statements aimed at providing guidance to clinicians on best practice use of TEHAs in patients with acute GIB’s. There was consensus on the need for future trials to compare use of different haemostatic powders in GIB’s.

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

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

Upper gastrointestinal bleeding (UGIB) continues to pose a significant threat to patients presenting at the emergency department, especially if the patients present with hemodynamic instability. There are still some uncertainties in the guidelines about the stepwise assessment and management for those patients before undergoing endoscopy.

Aims & Methods

Our study aims to report practice patterns to better understand the pre-endoscopic assessment for patients presenting with acute UGIB. This is an international online survey that included a prospective two-phase data collection. The distribution was conducted from April 2023 to November 2023. The target population was active physicians with clinical practices focusing on the management of patients with UGIB. Study data were collected and managed using Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey included four main sections (demographics and clinical practice, definition of hemodynamic instability, pre-endoscopy assessment, and optimal time for endoscopy) with a total of 33 relevant questions. The survey was endorsed by several national and international gastroenterology societies. The primary analysis was a descriptive assessment of individual survey response items in different domains. Descriptive statistics were reported as proportions. Secondary analysis evaluated differences in survey responses according to the years of clinical experience, type of practice location, and the estimated number of UGIB patients presented annually.

Results

In total, 533 clinicians completed our survey from 50 countries. Over half of the respondents work at university-based hospitals (54.6%) and have over 100 UGIB patients hospitalized annually (67.7%). In terms of clinical experience, 55.7% reported less than 10 years and 44.3% with more than 10 years. In 29.1% of the hospitals, there was no specific protocol or guideline for the initial assessment of patients with suspected UGIB, and in 44.7%, there were no emergency on-call interventional radiology services for such cases. Among the respondents, 39.6% do not use any risk stratification scores at the time of patient presentation. Both 0.9% saline (40.9%) and balanced crystalloid fluid (39.5%) were almost equally chosen as initial fluid resuscitation. However, the rate of fluid resuscitation was dependent on the hemodynamic status of 40.2% of the answers. In 40.7% of the answers, clinicians do not use any major hemorrhagic protocol for patients with severe ongoing bleeding and at risk of exsanguination. Prokinetics were generally little or never used prior to endoscopy in patients with UGIB (34.3%) or even in those with known gastric emptying problems (27.6%). The most chosen optimal time for endoscopy was within 24 hours for stable patients with non-variceal bleeding and within 12 hours for variceal bleeding. If patients were unstable but responding to resuscitation, the most chosen time was within 6 hours regardless of the source of bleeding and within 2 hours for those with persistent hemodynamic instability.

Conclusion

Adherence to international gastroenterology guidelines is low. There is a significant variability in different assessment approaches among respondents. Based on our data, the optimal time for endoscopy seems to be dependent on the hemodynamic status of patients with acute UGIB in both variceal and non-variceal bleeding. Our study highlights opportunities for improving consistency in reporting data and identifies potential areas for research.

Introduction

This study aims to assess the impact of antithrombotic therapy on endoscopic findings in patients hospitalized for upper gastrointestinal bleeding.

Aims & Methods

We carried out a prospective, single-center cross-sectional study including 332 patients between June 2020 and February 2025. Patients were classified as antithrombotic (AT) users if they were receiving antiplatelet agents (such as low-dose aspirin or thienopyridines) and/or anticoagulants (including vitamin K antagonists, direct oral anticoagulants, or heparin).

Results

The mean age of the study population was 59 ± 16.7 years, with a marked male predominance (77.1%). Among them, 63 patients (19%) were receiving antithrombotic (AT) therapy—41 on antiplatelet agents and 39 on anticoagulants. Patients in the AT group were significantly older (68 vs. 57 years; p < 0.001) and had a higher burden of comorbidities (75.8% vs. 16.7%; p < 0.001). However, there were no significant differences between the AT and non-AT groups regarding the presence of active bleeding at endoscopy (12.7% vs. 16.8%; p = 0.425) or the need for endoscopic hemostasis (7.9% vs. 16%; p = 0.1).
In multivariate analysis, after adjustment for age, sex, comorbidities, active bleeding, and AT use, only the presence of active bleeding was independently associated with the need for endoscopic hemostasis. Specifically, active bleeding at endoscopy increased the odds of requiring hemostasis by 26-fold (OR: 26, 95% CI: 12.9–62.15; p < 0.001), whereas AT therapy was not an independent predictor (OR: 0.386, 95% CI: 0.105–1.42; p = 0.154).

Conclusion

In older patients receiving antithrombotic therapy and admitted for upper gastrointestinal bleeding, the risk of active bleeding during endoscopy and the need for endoscopic hemostasis do not appear to be increased.