Introduction

Delayed bleeding is a rare but important major adverse event (mAE) after endoscopic submucosal tunneling procedures (ESTP), which is scarcely reported. We aimed to characterize the clinical characteristics of delayed bleeding and provide better management of this mAE.

Aims & Methods

From August 2010 to October 2022, we reviewed 3,852 patients with achalasia receiving peroral endoscopic myotomy (POEM) and 1,937 patients with upper GI tumors receiving submucosal tunneling endoscopic resection (STER). Among these, records of 22 patients (15 POEM, 7 STER) with delayed bleeding were collected. Clinical characteristics, treatment, and outcomes of delayed bleeding were analyzed.

Results

The mean age was 43.6 years. Ten patients (45.5%) were intratunnel bleeding, seven (31.8%) were intratunnel bleeding accompanied by mucosal bleeding, and 5 (22.7%) were mucosal bleeding. The most common accompanied symptoms were hematemesis, fever, and melena. The most common accompanied mAEs were fistula, pulmonary inflammation, and pleural effusion with atelectasis. The mean duration from ESTP to endoscopic intervention was 5.3±4.9 days. Active bleeding was identified in 21 patients (95.5%). The bleeding was successfully controlled by electrocoagulation (19 cases), endoscopic clipping (6 cases), and Sengstaken-Blakemore tube insertion (3 cases) and no patient required surgical intervention. The mean hemostatic procedure duration was 61.8±45.8 minutes. The mean post-bleeding hospital stay was 10.0±6.2 days. A brief meta-analysis of previous studies showed the pooled estimate delayed bleeding rare after POEM, STER, and G-POEM was 0.4%.

Conclusion

Delayed bleeding is uncommon and could be effectively managed by timely emergency endoscopic procedures without requiring subsequent surgical interventions.

Introduction

International guidelines recommend performing emergency gastroscopy within 12 hours for variceal (V) bleeding and within 24 hours for non-variceal (NV) bleeding in cases of upper gastrointestinal bleeding (UGIB).

Aims & Methods

This study aimed to analyze the time elapsed between emergency department admission and time of endoscopy, referred to as "door-to-endoscopy time" (DET), and to identify factors influencing DET across different UGIB subgroups. We conducted a retrospective cohort analysis of patients who underwent emergency gastroscopy for UGIB between January 1, 2022, and December 31, 2023, at the Department of Emergency Medicine at Semmelweis University. Data were collected on clinical parameters and 30-day mortality. NV patients were categorized into high-risk (HNV) and low- risk (LNV) groups based on endoscopic findings (Forrest classification). Welch’s t-test was used for comparing mean DET among the subgroups, whereas for hemoglobin linear regression was applied. The significance level was set at 0.05 for all analyses.

Results

Among 654 patients, we identified 126 V and 528 NV UGIB cases, with the latter comprising 99 HNV and 429 LNV cases. Rebleeding occurred in 5.4% of patients (V: 12.7%, HNV: 10.1%, LNV: 2.1%), and 30-day mortality was 19.7% in the cohort (V: 24.8%, HNV: 22.6%, LNV: 17.6%). The mean DET was 7.28 hours (SD=±6.04), with subgroup averages as follows: V: 5.87±3.77 hours, HNV: 6.33±4.04 hours, and LNV: 7.92±6.83 hours, with significant differences between LNV-HNV (p=0.003) and LNV-V (p<0.0001) groups; no significant difference was observed between HNV-V (p=0.37). In the entire cohort, shorter DET was significantly associated with tachycardia (6.61 vs. 7.73 hours, 95% confidence interval (CI) -1.99 to -0.25, p=0.01), hematemesis (5.82 vs. 8.09 hours, 95% CI -3.11 to -1.43, p<0.0001), syncope (6.25 vs. 7.57 hours; 95% CI -2.30 to -0.33, p=0.009), and lower hemoglobin levels (1 g/L decrease in hemoglobin reduced DET by an average of 1 minute, p=0.029). DET was not associated with 30-day mortality (p=0.501), vasopressor use (p=0.857), shock index (p=0.091), coffee-ground emesis (p=0.192), hematochezia (p=0.564), intubation (p=0.566), rebleeding rate (p=0.462), or melena (p=0.961). In the V group, DET was significantly shorter in case of hematemesis (5.20 vs. 7.25 hours, 95% CI -3.61 to -0.49, p=0.011) and tachycardia (5.19 vs. 6.64 hours, 95% CI -2.84 to -0.08, p=0.039); whereas in HNV patients with coffee-ground emesis, DET was significantly reduced (4.94 vs. 6.58 hours, 95% CI -3.08 to -0.20, p=0.026); in LNV patients, DET was shorter in patients with hematemesis (6.42 vs. 8.38 hours, 95% CI -3.20 to -0.71, p=0.002) and syncope (6.56 vs. 8.25 hours, 95% CI -3.10 to -0.29, p=0.019).

Conclusion

In our retrospective cohort study, DET significantly differed between LNV-V and LNV-HNV subgroups. Shorter DET correlated with tachycardia, hematemesis, syncope, and lower hemoglobin levels. DET showed no association with 30-day mortality or rebleeding rate.

Introduction

Acute upper gastrointestinal bleeding (AUGIB) is a common, life-threatening clinical emergency with considerable morbidity and mortality. It is postulated that AUGIB can lead to hypotension and hypoperfusion of the vital organs. In response to these changes, the body activates its compensatory mechanism deriving in higher levels of oxidative stress, inflammation, hypercoagulable state and vascular endothelial injury. All these put these patients in a higher risk of myocardial injury (MI), which may lead to increased mortality in AUGIB patients (1,2). However, older studies show similar mortality rates for those with AUGIB who develop MI (3,4).
Moreover, general abnormalities caused by AUGIB might well have delayed consequences with a significant impact on mortality (5).

Aims & Methods

Aim: To analyze the risk factors for in-hospital (ACVC) and delayed (DCVC) cardiovascular complications after AUGIB.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’ (2013-2020). Main outcomes were ACVC (including stroke, lung embolism, myocardial injury and heart failure) and DCVC-6months (including coronary syndrome, thromboembolic event, heart failure and arrhythmia). Statistical analysis was performed by SPSS.

Results

We included 1345 AUGIB patients, mean age 64.44 +/- 16.19, 32.3% females, 23 with ACVC (1.7%), 8 of these patients died. 79 develop DCVC (5.9%), 18 of these patients died.
Table show differences between patients with and without ACVC and DCVC.

ACVC	With	Without	HR (95%CI)	p
Age COPD Coronary disease Stroke High blood pressure Antiplatelets Urea at admission (mg/dL) Active bleeding Need for intervention Reebleeding Lenght hospital stay Inpatient In-hospital mortality	76.39 30.4% 34.8% 17.4% 69.6% 39.1% 147.17 56.5% 91.3% 26.1% 16.96 34.8% 36.4%	64.23 10.1% 9.6% 5.8% 43.7% 20.3% 86.51 27.5% 73.7% 9.9% 8.97 15.2% 10%	1.45 (1.10 - 2.33) 3.87 (1.56 - 9.59) 5.02 (2.10 - 12.07) 3.40 (1.13 - 10.25) 2.95 (1.20 - 7.21) 2.52 (1.08 - 5.88) 4.85 (1.75 - 11.23) 3.43 (1.49-7.90) 4.62 (1.70 - 12.52) 3.23 (1.25 - 8.33) 5.23 (2.34 - 14.53) 2.97 (1.24 - 7.10) 5.15 (2.12 - 12.52)	0.043 0.007 0.001 0.045 0.018 0.037 0.010 0.004 0.047 0.023 0.015 0.018 0.001
DCVC	With	Without	HR (95%CI)	p
Age COPD Cronic Kidney Disease Heart Failure Coronary disease Atrial fibrilation Valvular disease Stroke High blood pressure Anticoaugulants Urea at admission (mg/dL) Delayed bleeding Delayed mortality	74.46 19% 29.1% 39.2% 22.8% 49.4% 37% 15.2% 55.7% 49.4% 113.94 40.5% 23.1%	63.67 9.8% 13.7% 8.2% 9.4% 15.8% 7.3% 5.1% 43.5% 18.9% 83.36 12.9% 6.5%	1.56 (1.15 - 2.46) 2.16 (1.19 - 3.91) 2.59 (1.55 – 4.33) 7.25 (4.41 - 11. 93) 2.85 (1.63 - 5.00) 5.18 (3.24 - 8.28) 7.45 (3.20 - 17.31) 3.35 (1.72 - 6.53) 1.63 (1.03 - 2.58) 4.18 (2.62 - 6.65) 3.47 (1.83 - 6.25) 4.58 (2.83 - 7.42) 4.34 (2.44 - 7.72)	0.035 0.020 0.001 <0.001 0.001 0.001 < 0.001 0.001 0.046 <0.001 < 0.001 < 0.001 < 0.001

Independent risk factor for ACVC were age (HR 1.08, 95%CI 1.03-1.15, p=0.003), previous coronary disease (HR 2.98, 95%CI 1.05-9.48, p=0.045), urea (HR 1.007, 95%CI 1.002-1.013, p=0.011) and rebleeding (HR 3.85, CI95% 1.17-2.71, p= 0.027).
Independent risk factor for DCVC was previous heart failure (HR 5.92, 95%CI 2.17-16.17, p=0.001).

Conclusion

Patients with AUGIB who develop in-hospital cardiovascular events are older, have more comorbidities, more severe bleeding and worse outcomes. The independent risk factors for AUGIB induced cardiovascular event identified are age, previous coronary disease, urea and rebleeding. In the same way, patients with delayed cardiovascular event are older, have more comorbidities and worse delayed outcomes. The independent risk factor for AUGIB induced delayed cardiovascular event identified is previous heart failure.

References

1. Hao J, Dang P, Quan X, Chen Z, Zhang G, Liu H, Shi T, Yan Y. Risk factors, prediction model, and prognosis analysis of myocardial injury after acute upper gastrointestinal bleeding. Front Cardiovasc Med. 2022 Dec 8;9:1041062
2. Jiang GJ, Gao RK, Wang M, Xie TX, Zhan LY, Wei J, Sun SN, Ji PY, Tan DY, Lyu JJ. A Nomogram Model for Predicting Type-2 Myocardial Infarction Induced by Acute Upper Gastrointestinal Bleeding. Curr Med Sci. 2022 Apr;42(2):317-326.
3. Emenike E, Srivastava S, Amoateng-Adjepong Y, al-Kharrat T, Zarich S, Manthous CA. Myocardial infarction complicating gastrointestinal hemorrhage. Mayo Clin Proc. 1999 Mar;74(3):235-41.
4. Bhatti N, Amoateng-Adjepong Y, Qamar A, Manthous CA. Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes. Chest. 1998 Oct;114(4):1137-42.
5. Jiménez-Rosales R, Valverde-López F, Vadillo-Calles F, Martínez-Cara JG, López de Hierro M, Redondo-Cerezo E. Inhospital and delayed mortality after upper gastrointestinal bleeding: an analysis of risk factors in a prospective series. Scand J Gastroenterol. 2018 Jun;53(6):714-720.

Introduction

Managing leaks and defects of the upper gastrointestinal (UGI) tract remains challenging. Endoscopic Vacuum Therapy (EVT) is a promising option^1-3; However, data on its efficacy in large cohorts remain limited.

Aims & Methods

This retrospective study with prospectively collected data enrolled all consecutive patients with UGI defects treated by EVT at a single academic center (San Raffaele Hospital, Milan, Italy) from March 2015 to September 2024. The primary outcome was clinical success (CS). Secondary outcomes included median treatment duration/devices, technical success (TS) and adverse events (AEs). Clinical success (CS) was defined as complete endoscopic and/or radiologic defect healing, with the patient remaining asymptomatic. Adverse events (AEs) were classified according to the AGREE classification.

Results

Over a period of 114 months, 96 patients [72.9% male, median age 67 years (IQR 57-75), 49% ASA 3] were included. Among them, 66 patients (68.7%) had anastomotic leaks after Ivor-Lewis esophagectomy, with 57% undergoing neoadjuvant chemotherapy. The median leak size was 7 mm (IQR 4-10), with a median circumferential involvement of 20% (IQR 10-40). A fistula involving the airways was present in 28.1% of cases. EVT was the first-line treatment in 78.1% of patients, with a median time from surgery to EVT of 7 days (IQR 4-9).
The overall clinical success (CS) rate was 72.9% (70/96 patients). Of the remaining patients, 20 underwent redo-surgery. Technical success for all procedures was 100% (302/302 procedures). The median treatment duration was 11 days (IQR 5-18), with a median of 3 EVT sessions (IQR 2-4). Three adverse events (AEs) (3/302, 1%) were recorded, including one bleeding episode and two sponge dislodgments, all managed endoscopically (AGREE IIIa). During a median follow-up of 62 days (IQR 33-155), two cases (2.1%) of esophageal strictures were reported (Table 1)
In the subgroup analysis, the intraluminal (IL) group (n=70) had a lower mean number of EVT sessions (3±2 vs. 5±3, p<0.001) and a shorter mean treatment duration (11±10 vs. 21±16 days, p<0.001) compared to the intracavitary (IC) group (n=26).

Table 1: Outcomes

Patients n=96	Median (IQR) OR n (%)
Clinical success, n	70 (72.9%)
Technical success, n	302/302 (100.0%)
Adverse events, n	3/302 (1%)
Treatment duration (days)	11 (5-18)
Number of EVT sessions	3 (2-4)
Hospital stay (days)	28 (17-43)
ICU admission, n	14 (14.9%)
Stricture, n	2 (2.1%)
Follow-up (days)	62 (33-155)

Conclusion

EVT is a safe and effective treatment for UGI defects. The IL approach was associated with shorter treatment duration and fewer sessions compared to the IC approach. Further controlled studies are needed to optimize EVT application and outcomes.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x

Introduction

Massive gastrointestinal bleeding (MGB) is a life-threatening condition that requires prompt recognition and resuscitation to increase the chance of good outcomes (1).

Aims & Methods

Aims: Analyze risk factors, comorbidities and outcomes of MGB.
Methods: Retrospective analysis of a prospective registry of upper gastrointestinal bleed (UGIB) patients admitted to ‘Virgen de las Nieves University Hospital’ between 2013-2020.
MGB was defined as UGIB with transfusion of >2 pRBCs in the emergency room or during the first 24h of hospital stay and signs of shock (2). Main outcomes were 30-day mortality, rebleeding, bleeding persistence or severe complication throughout admission and complications within the first 6 months after discharge (including cardiovascular, hemorrhagic or deaths).
Statistical analysis was performed by SPSS.

Results

We included 1213 UGIB patients, 171 with MGB.
Multivariate logistic regression analysis showed that, being admitted for another condition (HR 1.72,95%CI 1.04-2.58,p=0.035), having a systemic disease (HR 2.30,95%CI 1.22-5.32,p=0.045), a disseminated malignancy (HR 2.07,95%CI 1.02-4.21,p=0.045) or suffering a severe comorbidity (HR 2.21,95%CI 1.25-3.91,p=0.009) were independent risk factor for MGB.
Among 171 MGB patients, 21% died, with 10 deaths directly from hypovolemic shock secondary to UGIB, and 11% due to complications.
Table shows significance differences between deaths and survivors.

Relevant Comorbidities ASA 3-4 (%)	Deaths 96.7%	Survivors 78.5%	p 0.0018
Active bleeding (%)	76.3	43.3	0.007
Interventional radiology (%)	13.3	3.7	0.034
SBP (mean±SD mmHg)	79±8	84±9	0.025
Albumin (mean±SD mg/dl)	2.4±0.5	2.8±0.6	0.011
Calcium (mean±SD mg/dl)	7.7±0.6	8.2±0.8	0.032
Platelets (mean±SD /mm3)	158*103±101*103	206*103±106*103	0.027
Severe complications during hospitalization	76.7	22.1	<0.0001
Bleeding persistence (%)	63.3	17.6	<0.0001
Rebleeding (%)	40	17	0.005

Multivariate analysis showed that active bleeding in endoscopy (HR 4.80,95%CI 1.06-21.62,p=0.041) and severe complications (HR 14.03,95%CI 3.30-59.60,p<0.0001) were independent predictors for mortality, being calcium levels a protective factor (HR 0.41,95%CI 0.16-0.94,p=0.045).
Among the survivors after the index episode,14% died after 6 months, being main causes of death recurrent bleeding(5.2%), neoplasms(4.4%), cirrhosis complications(2%), cardiovascular disease(1.5%) and sepsis(1.5%).
Delayed bleeding was caused by recurrent UGIB in 86.6%, lower GIB in 10% and from a non-GI origin in 3.4%. Delayed cardiovascular events were heart failure in 46%, thromboembolic events in 23%, myocardial ischemia in 15.4% and atrial fibrillation in 15.6%.

Conclusion

Our study is a prospectively collected single center registry of patients with massive UGIB, in which we observed that being an inpatient and harboring severe comorbidities, particularly systemic diseases and malignancies, were risk factors for this condition. Mortality among those patients was related to CKD, cirrhosis, severe comorbidities and excessive alcohol consumption. We also found an increased delayed mortality, probably related to a worsening health condition in which GI bleeding heralded poor outcomes, some of them potentially preventable with close follow-up.

References

1. Nagata N, Sakurai T, Shimbo T, et al. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol. 2017;15:1882-1889 e1881.
2. D'Amore K, Swaminathan A. Massive Gastrointestinal Hemorrhage. Emerg Med Clin North Am. 2020;38:871-889.

Introduction

Background and aims: Repeat peroral endoscopic myotomy (Re-POEM) appeared to be a promising salvage option for patients with persistent/recurrent symptoms after initial POEM, but it may be more.

Aims & Methods

Between July 2012 and October 2023, 158 achalasia patients underwent Re-POEM were retrospectively enrolled in this study. Another 2978 patients without prior myotomy were selected for naïve POEM. After propensity score matching (PSM), procedure-related parameters were compared between the two groups. Univariable and multivariable analyses were performed to reveal risk factors for difficult Re-POEM.

Results

With similar baseline characteristics between two groups after PSM, the procedure time was comparable between Re-POEM and naïve POEM groups (61.4±27.0 vs. 59.3±29.9, p=0.496). The Re-POEM group showed shorter esophageal myotomy length (7.0±2.1 vs. 8.2±1.1, p<0.001) and longer gastric myotomy length (2.3±0.6 vs. 2.1±0.4, p=0.017), compared with the naïve POEM group. Mucosal injury in Re-POEM group was slightly higher, which was not statistically significant (20.3% vs. 13.9%, p=0.135). No differences were found in the incidence of gas-related adverse events (AEs), major AEs, and technical difficulty. Multivariate analysis determined mucosal edema (OR=4.942, 95% CI, 1.554-15.714, p=0.007) and submucosal fibrosis (OR=3.817, 95% CI, 1.333-10.931, p=0.013) to be independent risk factors for difficult Re-POEM.

Conclusion

Re-POEM appears safe and feasible as a salvage option after initial POEM failure, with comparable procedure duration, incidence of AEs and technical difficulty to naïve POEM. Mucosal edema and submucosal fibrosis were associated with difficult Re-POEM.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.